o 

T&IE  WILLIAM  PEPPER  LIBRARY 

1  (T..vssGl4»4l3x,,  C^LH 


LECTURES 

ON  THE 

THEORY  AND  PRACTICE  OF  VACCINATION. 


LECTURES 

ON  THE 

THEORY  AND  PRACTICE 

OF 

VACCINATION. 


BY 

ROBERT  CORY,  M.A.,  M.D.  Cantab.,  F.R.C.P.  Lond., 

PHYSICIAN    IN    CHARGE    OF    THE    VACCINATION    DEPARTMENT    OF    ST.    THOMAS'S  HOSPITAL 
TEACHER  OF  VACCINATION  IN  THE  UNIVERSITY  OF  CAMBRIDGE,  FTC. 


NEW  YORK: 
WILLIAM   WOOD  &  COMPANY. 


TO  THE 
MEMORY  OF  MY  DEAR  FRIEND 

SIR  GEORGE  BUCHANAN,  F.R.S., 

WHOSE  EXAMPLE  WAS 
AN  ENSIGN  TO  ALL  THAT   WAS  TRUE  AND  NOBLE, 
BUT  AS  A  DRAG   TO  THAT  WHICH  WAS 
FALSE   AND  DISHONOURABLE. 


Digitized  by  the  Internet  Archive 
in  2013 


http://archive.org/details/lecturesontheoryOOcory 


PREFACE. 


For  the  last  twenty-two  years  I  have  been  engaged  in  the 
practice  and  teaching  of  vaccination.  The  six  chapters 
contain  the  substance  of  the  six  lectures  I  periodically 
deliver  to  my  pupils,  together  with  the  incorporation  of 
several  papers  which  I  have  from  time  to  time  published 
in  the  periodicals,  and  now  for  the  first  time  publish 
in  book  form.  The  whole  of  the  work  was  written  before 
the  final  report  of  the  Royal  Commission  on  Vaccination 
was  issued,  except  a  short  paragraph  on  page  8  and  the 
completion  of  the  report  of  the  first  case  given  on  page  60. 
I  am  not,  therefore,  indebted  to  this  for  any  information, 
and  it  may  be  taken,  so  far  as  I  am  concerned,  as  entirely 
independent. 

ROBERT  CORY. 

73,  Lambeth  Palace  Road,  S.E., 
December,  1897 


CONTENTS 


LECTUEE  I. 

PAGE 

THE  REASONS  WHICH  LED  THE  LEGISLATURE  OF  THIS  COUNTRY 
TO  IMPOSE  THE  VACCINATION  LAWS  UPON  THE  PEOPLE, 
AND  THE  DUTY  ENTAILED  UPON  EVERY  MEDICAL  MAN 
TO  SUPPORT  THOSE  LAWS  AT  THE  PRESENT  TIME        -  1 

LECTUEE  IX 

HISTOLOGY  OF  THE  VACCINE  AND  SMALL-POX  VESICLES      -  41 

LECTUEE  III. 

THE  DIFFERENCE   BETWEEN  A  PRIMARY  AND  A  SECONDARY 

VACCINATION      -  -  -  -  -  -  48 

LECTUEE  IV. 

THE  ERUPTIONS  THAT  OCCASIONALLY  FOLLOW  VACCINATION  63 

LECTUEE  V. 

THE  PRACTICAL  DETAILS  OF  VACCINATION  -  -  -  69 

LECTUEE  VI. 

ON  THE  RELATION  OF  COW-POX,  HORSE-POX,  AND  CAMEL- 
POX  TO  SMALL-POX        -----  1Q4 


LECTURES 

ON  THE 

THEORY  AND  PRACTICE  OF  VACCINATION 


LECTUKE  I. 

THE  EEASONS  WHICH  LED  THE  LEGISLATURE  OF  THIS  COUNTRY 
TO  IMPOSE  THE  VACCINATION  LAWS  UPON  THE  PEOPLE, 
AND  THE  DUTY  ENTAILED  UPON  EVERY  MEDICAL  MAN  TO 
SUPPORT  THOSE  LAWS  AT  THE   PRESENT  TIME. 

A  good  introduction  to  the  study  of  vaccination  is  a  con- 
sideration of  the  reasons  that  led  the  legislature  of  this 
country  to  impose  the  vaccination  laws  upon  the  people, 
and  the  duty  entailed  on  medical  men  to  support  those  laws 
at  the  present  time.  This  consideration  is  now  all  the 
more  called  for,  as  we  no  longer  have  the  horrors  of  natural 
small-pox  before  us  ;  the  unthinking  are  apt  to  overlook 
them  and  thus  to  magnify  the  nugatory  evils  of  vaccina- 
tion, forgetting,  or  not  considering,  the  saving  of  life  and 
misery  which  we  derive  from  it. 

Mr.  Cross,  writing  in  1820  of  the  epidemic  of  small-pox 
which  visited  Norwich  in  1819,  says  in  conclusion  : 

•  I  advocate  vaccination  because  I  believe  it  to  be  the 
most  powerful  means  of  preventing  the  misery  attendant 
on  disease,  and  of  saving  human  life,  which  Providence  has 
vouchsafed  to  put  into  the  hands  of  man  ;  my  time  has  been 
given  up  to  the  gratuitous  practice  of  it,  because  I  can  thus 
do  more  good  amongst  the  poor  than  by  prescribing  pills 
and  potions,  and  I  regard  every  drop  of  the  vaccine  ichor 
as  the  most  active  material  that  can  be  admitted  into  the 
list  of  our  prophylactic  remedies.  I  am,  therefore,  grateful 
to  the  philosopher  who  has  taught  us  to  wield  this  weapon 
of  defence  in  overcoming  the  icorst  of  human  maladies. 

1 


2  THEORY  AND  PRACTICE  OF  VACCINATION 


'  The  more  we  reflect  upon  the  professional  career  of 
Jenner,  the  more  must  he  excite  our  admiration  for  the 
scientific  investigations  by  which  he  established  his  dis- 
covery— the  nobleness  with  which  he  gave  it  fully  to  the 
public — the  temper  and  ability  with  which  he  defended  it 
against  opponents  often  not  of  the  best  character.  May  his 
life  be  uniformly  happy,  and  his  name  immortal  !'* 

Such  was  the  opinion  of  Mr.  Cross,  writing  in  1820 ;  and 
be  it  remembered  that  the  discovery  of  vaccination  had 
only  been  published  twenty-two  years,  and  its  adoption  had 
not  become  general,  consequently  he  was  writing  with  most 
of  the  horrors  of  small-pox  still  before  him.  He  calls 
small-pox  '  the  worst  of  human  maladies.'  Worst,  because 
it  was  the  most  common,  and  withal  the  most  fatal  disease 
to  which  the  human  race  was  liable ;  scarring,  or  not 
unfrequently  blinding,  those  it  did  not  destroy. 

Of  those  who  died  in  London  from  all  causes,  small-pox 
occasioned  death  in  one-twelfth — that  is  to  say,  the  average 
yearly  deaths  from  small -pox  would  have  been  6,577,  if 
the  same  mortality  was  occasioned  by  it  at  the  present 
time  as  was  occasioned  by  it  in  the  last  century,  instead  of 
only  1,227,  which  is  the  actual  average  mortality  from  small- 
pox in  London  for  a  like  period,  and  that  period  embraces 
the  great  epidemic  of  1871.  The  average  yearly  deaths 
from  small-pox  that  occurred  between  the  period  of  1867 
and  1885,  and  the  annual  average  of  deaths  from  all  causes, 
have  been  taken  for  the  above  comparison,  as  it  is  wished 
to  show,  as  far  as  possible,  the  effects  of  vaccination  alone 
on  small-pox.  1867  was  the  year  of  the  Amended  Vaccina- 
tion Act,  and  1885  was  the  year  when  deportation  of  small- 
pox first  took  place  from  London,  and  deportation  seems  to 
have  had  a  very  great  influence  in  diminishing  the  disease. 

The  diminution  of  small-pox  must  be  looked  at  from  at 
least  two  sides  ;  that  is  to  say,  from  the  diminished  in- 
fectibility  of  the  population,  which  is  what  vaccination  is 
capable  of  bringing  about,  and  also  from  the  diminished 

*  '  A  History  of  the  Variolous  Epidemic  which  occurred  in  Norwich 
in  1819,'  by  John  Cross. 


THEORY  AND  PRACTICE  OF  VACCINATION 


infectiveness  of  the  disease,  which  is  what  deportation  is 
capable  of  doing. 

Mr.  Power,  the  Assistant  Medical  Officer  of  the  Local 
Government  Board,  has  shown,  in  the  report  of  the  Board 
for  1880-81,  that  small-pox  was  especially  prevalent  round 
about  the  small-pox  hospital  at  Fulham,  and  this  prevalence 
could  not  be  attributed  to  direct  personal  infection.  Some- 
thing akin  to  this  observation  of  Mr.  Power's  had  been 
noticed  by  Mr.  Cross  during  the  Norwich  epidemic  of  small- 
pox in  1819.  For  he  writes,  '  It  is  certain  that  the  epidemic 
at  its  commencement  was  milder.  The  first  petechial  case 
which  I  saw  was  in  the  latter  end  of  May.  The  virulence 
of  the  contagion  seemed  to  keep  pace  with  the  increasing 
prevalence  of  the  disease,  and  to  be  heightened  in  proportion 
to  the  number  suffering  from  it  at  one  time.'* 

To  Mr.  Power,  however,  we  are  indebted  for  having  con- 
clusively shown  that,  from  the  segregation  of  cases  of  small- 
pox at  the  Fulham  Small-pox  Hospital,  small-pox  was 
rendered  more  prevalent  in  the  region  of  the  hospital. 

Further  evidence  on  this  point  may  be  gathered  from, 
first,  the  epidemic  which  took  place  at  Sheffield  in  1887-88.  f 
Here  there  was  a  hospital  for  small- pox  in  a  populous 
neighbourhood,  and,  as  with  the  epidemic  at  Gloucester, 
where  similar  conditions  existed,  reported  on  by  Dr.  Sidney 
Coupland,  the  epidemic  of  small-pox  was  severe.  On  the 
other  hand,  at  Leicester,  where  the  small-pox  hospital  is 
situated  outside  registration  Leicester,  small-pox  is  apparently 
trifling.  '  Outside  registration  Leicester '  is  mentioned 
because  it  is  not  wished  to  attach  undue  weight  to  the 
argument.  Pains  are  taken  at  Leicester  to  remove  as  early 
as  possible  cases  of  small-pox  to  the  hospital,  and  if  the 
patient  dies,  the  case  is  not  registered  in  Leicester,  but  in 
the  district  where  the  hospital  is  situated ;  hence,  Leicester 
appears  freer  from  small-pox  than  is  actually  the  case. 

*  '  A  History  of  the  Variolous  Epidemic  which  occurred  in  Norwich 
in  1819,'  by  John  Cross,  p.  14. 

t  Report  on  an  Epidemic  of  Small-pox  at  Sheffield,  1887-88,  by  Dr. 
Barry,  of  the  Local  Government  Board. 

1—2 


4 


THEORY  AND  PRACTICE  OF  VACCINATION 


The  outcome  of  Mr.  Power's  observations  was,  that  cases 
of  small-pox  when  notified  have  been  sent  out  of  London 
to  ships  or  hospitals  quite  away  from  human  habitation. 
The  result  has  been  quite  phenomenal ;  for  small-pox  deaths, 
which  on  the  average  for  the  ten  previous  years  to  the 
deportation  of  small-pox  had  been  1,121,  fell  in  the  succeed- 
ing nine  years  to  a  yearly  average  of  only  43*4,  or  of 
what  they  had  been. 

But  diminished  number  of  deaths  from  small -pox  is  only 
a  part  of  the  good  derived  from  vaccination,  for  those  whom 
small-pox  slays  at  the  present  day  have  attained,  on  the 
average,  to  at  least  fifteen  years'  longer  life  than  those  who 
died  from  it  in  pre- vaccination  times. 

Small-pox,  before  the  introduction  of  vaccination,  was 
really  a  disease  of  childhood,  as  whooping-cough,  measles, 
and  scarlet  fever  are  at  the  present  day,  and  consequently 
nearly  the  whole  death-rate  used  to  fall  upon  the  children, 
just  as  the  above-named  diseases  do  at  the  present  time, 
and  individuals  did  not  have  small-pox  later  in  life  because 
they  had  obtained  their  protection  by  having  had  an  attack 
in  infancy.  That  this  was  the  case  may  be  gathered  from 
records  of  the  deaths  from  small-pox  at  Warrington,  at 
Chester,  at  Kilmarnock,  at  Manchester,  and  from  Geneva. 
The  following  table  (Table  I.)  has  been  drawn  up  to  show 
the  age,  as  far  as  possible,  at  time  of  death  from  small-pox 
at  these  places  in  pre- vaccination  times.  It  will  be  seen 
that  83-15  per  cent,  of  the  deaths  from  small-pox  occurred 
in  children  under  5  years  of  age,  and  as  many  as  96*75 
occurred  in  children  under  10  years.  At  the  present  time 
the  greatest  number  of  deaths  from  small-pox  among  those 
who  have  been  vaccinated  in  infancy  takes  place  between 
the  ages  of  20  to  40,  and  not  in  early  childhood  as  in  the  pre- 
vaccination  times.  See  a,  Table  II.,  p.  6.  In  Table  III.,  p.  6, 
the  ages  in  the  pre-vaccination  times  and  the  present  time 
are  contrasted. 

This  later  table  shows  how  greatly  the  age  of  death  from 
small-pox  has  been  altered.  This,  no  doubt,  is  partly  due 
to  the  present  opportunities  of  being  affected  by  small-pox 


THEORY  AND  PRACTICE  OF  VACCINATION 


rQ  O 

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6 


»  CD 
ill 

O 


Total. 

r-i                 <N               "M  OS 
O                  O  OO 
CN                 CN               CO  IO 

1664 

6792 

8456 

Age  not 
stated. 

Years 
20-40. 

CN 
>— 1  rH 

^6 

o 

NH  OO 

_  CN 

rH 

OO 

CO 

Cl  • 

Years 
10-20. 

«P  r-rr1 
o  o 

CO 

180 

£i  0O 

185 
2-19 

Years 
5-10. 

12 
4-78 

22 
10-89 

21 

3-  38 

29 

4-  92 

o 
CO  • 
ICS 

1058 

10  Oo 

1142 
13-60 

Years 
1-5. 

O                   CO                   -*±l  HH 
Oj^.             C5  OO           OOCN  CirH 

os  •           cn  •         co           r-i  -  , 

H  «                   T—iro               tH       O  H 

CO  W 

<°  22 

o  7^ 

^  CN 

cs 

"'H  O 
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^£ 

no  • 

O  CO 
W  OO 

Year 
0-1. 

CN                 \0                 1^  W 

C5»P                 r-|tN              ^      05          ^  V" 

**C5              ^  O           rHCO        h  W 
r-l                   (N                   r-H  CM 

358 
21-51 

Warrington,  1773  ... 
Per  cent  

Chester,  1774* 

Per  cent  

Kilmarnock,  1728-64 
Per  cent  

Manchester,  1768-74 
Per  cent  

Total  

Per  cent.   . . . 

Geneva.,  1580-1760  ... 
Per  cent  

Total  

Per  cent.   . . . 

2 "  • 

o  So 

r-i  ^OO 


■a  2^ 


^  13  H 


.  ©.a 

O  S  2 
O  ^  r> 


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o 


6  THEORY  AND  PRACTICE  OF  VACCINATION 

Table  II. 


A.  VACCINATED  BEFORE  DEPORTATION. 


Years. 

Age 

Age 

Age 

Age 

Age 

Age 

80  and 

Deaths  from  all 

0-1. 

1-5. 

5-20. 

20-40. 

40-60. 

60-S0. 

upwards. 

causes. 

1882 

1 

3 

21 

57 

20 

5 

1 

82,905 

1  QQO 

looo 

1 

7 

27 

7 

80,578 

1884 

1 

7 

38 

142 

56 

6 

83,050 

1885 

4 

2 

35 

135 

32 

9 

1 

80;000 

Total  ... 

6 

13 

101 

361 

115 

20 

2 

326,483 

Per  cent. 

0-97 

2-1 

16-34 

58-41 

18-61 

3-24 

0-32 

Total  cases,  618  = 

=  0*19  per  cent,  to  total  deaths. 

B.- 

— UNVACCINATED  BEFORE 

DEPORTATION. 

Years. 

Age 

Age 

Age 

Age 

Age 

Age 

80  and 

Deaths  from  all 

0-1. 

1-5. 

5-20. 

20-40. 

40-60. 

60-80. 

upwards. 

causes. 

1882 

22 

34 

68 

49 

11 

1883 

12 

12 

18 

10 

2 

1 

1884 

60 

84 

92 

60 

19 

3 

1 

1885 

66 

55 

110 

74 

19 

6 

Total  ... 

160 

185 

288 

193 

51 

10 

1 

Per  cent. 

18-02  !  20-84 

1 

32-43 

21-73 

5-74 

1-13 

o-ii 

Total  cases,  888  =  0-27  per  cent,  to  total  deaths. 

Table  III. 


Age 
0-5. 

Age 
5-10. 

Age 
10-20. 

Age 
20-40. 

Age 
40-60. 

Age 
60-80. 

80  and 

up- 
wards. 

Pre -vaccination  times  - 
Present 

83-15 
3-07 

15-  79 

16-  34 

15-  79 

16-  34 

1-16 

58-41 

0 

18*61 

0 

3-24 

0 

•32 

being  so  much  less  than  they  were  formerly.  But  it  must 
be  mainly  due  to  the  evanescent  protection  which  infantile 
vaccination  gives. 

The  protective  power  of  vaccination  is  further  shown  in 
Table  IV.,  which  was  drawn  up  by  the  late  Dr.  Carsten,  of 
the  Hague.  It  gives  the  average  deaths  from  small-pox  in 
Germany  before  compulsory  vaccination  at  the  age  of  12 
was  enforced,  and  also  the  annual  deaths  from  small-pox 
since.  The  same  is  also  given  for  Holland  as  far  as  possible, 
for  Holland  has  no  direct  compulsory  law.    Every  child  in 


Table  IV. 


PR  USS1A.  •  HOLLAND. 

With  CvmpuLsorvYarriiialioii  Wiih  Compulsory 

ti/ifi  Compulsory Re^cuxurtoctioTt,.  VaxxxnutLon  of  ChzLdrerv 
at  th#<  Ag&  of  12.  before,  eiUjering  a  School  . 


AUSTRIA 

Without  Qimpulsoiy 
VcLcd  natxDn, . 


Before  the 
L  cuv. 


After  the  Law  of  1874- 

was  passed,. 


II  .ill... 


Before  the; 
Law. 


After-  Our  Law  of  1873 
was  passed 


li|_iJ 


1.1 


-J2C 


_II0 


^00 


-90 


JSO 


.60 


50 


40 


80 


W 


-JO 


1868-1874  KSPSSSSxSwSSS 
lua  ape  yearly  * 

Deaths  from     Annual  Deaths  from 

'^ICVOOO  ^ma^/  ^ooc  >n/  every 
InhaiUcvas    100,000  Inhabitants. 


1866-1872 

Average  \earlv 
Broth/  from, 
Small  Poa  in 
everv  WO.CCC 
Inhabitant v 


c 

Annual  Deaths  from 
Small   Poo-  in  every 
100,000 Inhabitants. 


1868  1874 

Average  yearly 
Deaihsfronv 
Small  -Pox  in 
every  WOflOO 
Inliabitante . 


IS3 


Antuial  Deaths  from 
Small  -Pox  in  every 
100,000  Inhabitants. 


West  Newma/n  H.th. 


THEORY  AND  PRACTICE  OF  VACCINATION  7 


Holland  has  to  be  vaccinated  before  it  enters  a  school,  and 
the  law  compels  every  child  to  be  sent  to  school.  The  same 
is  given  for  Austria,  where  there  is  no  compulsory  vaccination 
of  any  kind,  and  here  it  will  be  seen  how  the  annual  deaths 
from  small-pox  remain  high.  The  protective  power  of  vac- 
cination is,  moreover,  shown  by  examination  of  the  arms  for 
vaccination  scars  among  those  who  are  pitted  with  small-pox. 

Since  November,  1884,  I  have  observed,  whenever  pos- 
sible, the  scars  of  vaccination,  if  such  existed,  on  every 
person  who  had  become  pitted  with  the  small-pox  which 
came  before  me  at  St.  Thomas's  Hospital  and  at  the 
vaccination  stations  with  which  I  am  connected.  These 
persons  have  been  almost  all  women ;  indeed,  out  of  456 
cases  in  which  inspection  was  permitted,  only  19  were  among 
males.  Every  case  examined  is  given  in  Table  VI.,  p.  12.  In 
18881  had  collected  152  cases,  which  were  published  in  the 
'  Transactions  of  the  Epidemiological  Society '  for  1887-88. 

In  what  follows  hereafter,  Cases  24,  37,  65,  96,  131, 
246,  274,  and  362  are  eliminated  from  consideration  for 
the  following  reasons :  Cases  24,  37,  and  362,  because  the 
vaccination  took  place  during  the  incubatory  period  of 
small-pox ;  Cases  65,  131,  and  274,  because,  although  they 
had  some  indistinct  mottling,  it  was  impossible  to  conclude 
with  any  certainty  that  this  was  the  result  of  vaccination  ; 
Case  96,  because  from  the  history  it  seemed  certain  that 
she  had  not  had  her  attack  of  small-pox  until  eleven  years 
old,  although  she  stated  that  she  had  had  two  attacks,  one 
at  two  years  of  age,  the  other  at  eleven  years  of  age ;  and 
lastly,  Case  246  because  I  was  not  permitted  to  examine 
the  arm.  There  are,  therefore,  456  —  8  =  448  cases  to  be 
dealt  with.  Out  of  these  448  cases  there  are  210  who  were 
admittedly  unvaccinated  before  their  attack  of  small-pox,  or 
46*87  per  cent. ;  and  these  admittedly  unvaccinated  people 
had  their  small-pox  at  the  average  age  of  6*58  years,  as  will 
be  seen  at  the  end  of  Table  VII.,  p.  29.  This  age  is  indeed 
high  when  compared  with  the  average  age  individuals  were 
attacked  with  the  disease  in  the  last  century.  However, 
there  are  three  circumstances  to  be  borne  in  mind  :  Firstly, 


8 


THEORY  AND  PRACTICE  OF  VACCINATION 


the  greatly  diminished  prevalence  of  small-pox  in  the  present 
day  to  that  which  obtained  in  the  last  century.  It  follows, 
therefore,  that  the  opportunity  to  become  affected  is 
correspondingly  not  so  great,  and  this  would  delay  the 
average  age  at  which  unvaccinated  individuals  contract  the 
disease.  Secondly,  a  large  proportion  of  the  unvaccinated 
individuals  die  of  the  disease,  and  these  would  in  the  main 
be  the  infants  ;  hence  we  have  a  considerable  portion  of  the 
youngest  eliminated  by  death.  And,  thirdly,  only  those 
who  have  been  obviously  pitted  with  small-pox  are  dealt 
with.  There  are  some  individuals  who,  although  they  have 
had  the  disease,  yet  are  not  obviously  pitted.  If  these 
could  be  added,  no  doubt  the  average  age  would  be 
diminished  at  which  small-pox  attacks  the  unvaccinated. 
There  are,  besides  the  admittedly  unvaccinated,  as  many 
as  105  individuals  who,  although  they  say  they  have  been 
vaccinated,  yet  have  no  scar  of  vaccination,  or  23*44.  As 
a  matter  of  fact,  there  are  as  many  as  70*31  per  cent, 
among  those  who  are  pitted  with  the  small-pox  who  bear 
no  evidence  of  vaccination.  An  opinion  can  be  formed 
of  how  many  of  the  latter  class  may  be  reckoned  among 
the  unvaccinated  thus  :  At  Lamb's  Conduit  Street  Vaccina- 
tion Station,  since  it  was  opened  in  1882  until  March  in 
the  present  year,  1,774  women  have  been  revaccinated. 
Of  these  82  had  no  scar  of  their  primary  vaccination,  and 
22  out  of  the  82  went  through  their  presumed  revaccina- 
tion  exactly  like  a  primary  vaccination,  or  26*83  per  cent. 
On  the  other  hand,  out  of  1,692  women  who  bore  scars 
of  vaccination,  it  was  found  that  47  of  them  went  through 
their  revaccination  like  a  primary  vaccination  in  all  respects, 
or  2*78  per  cent.  If  now  this  latter  percentage  be  deducted 
from  the  26*83  per  cent.,  we  obtain  24*05  per  cent,  as  the 
number  who  really  had  never  been  vaccinated. 

From  these  data  we  can  calculate  that  of  the  105  cases 
which  have  no  scar  of  vaccination,  25*25  should  be  added  to 
the  210  admittedly  unvaccinated ;  this  will  give  then  235*25 
as  really  the  number  of  unvaccinated  among  the  448  cases, 
or  52*51  per  cent. 


THEORY  AND  PRACTICE  OF  VACCINATION  9 


Now,  the  proportion  of  the  unvaccinated  to  the  vaccinated 
in  London  is  not  more  than  5  per  cent.,  yet  we  have  seen 
that  people  pitted  with  small-pox  are  to  the  extent  of  52*51 
per  cent,  unvaccinated ;  and  if,  as  some  contend,  there  is 
no  protective  power  in  vaccination  against  the  small-pox, 
what  is  the  meaning  of  this  ?  I  leave  this  question  to  be 
answered  by  those  who  hold  the  above  view.  For  myself, 
I  am  content  to  believe  there  is  protection  afforded  by 
vaccination  against  small-pox,  and  adduce  this  as  one  out 
of  many  proofs  that  such  is  the  case. 

At  the  end  of  Table  VII.,  p.  33,  it  will  be  seen  that  the 
average  age  of  105  individuals  who  affirm  they  have  been 
vaccinated,  but  have  nevertheless  no  scar  of  vaccination,  is 
9*07  years  when  they  are  attacked  by  small-pox,  and  it  has 
just  been  seen  there  is  good  reason  for  believing  that  25*25 
of  them  have  never  really  been  successfully  vaccinated ; 
and  as  the  average  age  at  which  the  admittedly  unvac- 
cinated have  their  small-pox  is  6*58,  therefore  6*58x25*25 
=  166*14,  which  is  the  aggregate  age  at  which  we  may 
reasonably  suppose  they  had  their  small  -  pox.  This 
deducted  from  952*64  years,  the  aggregate  age  at  which 
people  affirm  they  have  been  vaccinated  but  have  no 
scar,  equals  786*5,  and  this  divided  by  105-25*25  =  79*75, 

j^y|  =  9*86.    Hence  this  is  the  average  at  which  those 

who  may  be  supposed  to  have  been  really  vaccinated,  but 
who  bear  no  scar  of  vaccination,  have  their  small-pox. 

From  Table  VII.  it  will  also  be  seen  that  those  who  bear 
one  scar  of  vaccination  have  their  small-pox  at  the  average 
age  of  17*77,  the  earliest  age  being  2.  That  those  who 
have  two  scars  of  vaccination  have  their  small-pox  at  the 
average  age  of  17*82,  the  earliest  age  being  7.  That  those 
having  three  vaccination  scars  have  their  small-pox  at  the 
average  age  of  18*02,  the  earliest  age  being  9.  That  those 
having  four  vaccination  scars  have  their  small-pox  at  the 
average  age  of  18*67,  the  earliest  age  being  12  ;  and  those 
having  five  or  more  scars  have  their  small-pox  at  the 
average  age  of  19  3,  the  easiest  age  being  13. 


io        THEORY  AND  PRACTICE  OF  VACCINATION 

It  will  be  noticed  not  only  does  the  average  age  at  the 
time  of  having  small-pox  increase  directly  as  the  number 
of  the  scars,  but  also  the  earliest  age  at  which  people 
become  liable  to  contract  small-pox  after  vaccination  also 
increases  in  the  same  way,  so  that  we  may  conclude  that 
vaccination  done  in  five  places  gives  a  longer  time  of 
immunity  from  small-pox  than  when  it  is  only  done  in 
one.  It  has  been  stated  that  Cases  24,  37,  362,  were 
eliminated  from  consideration,  because  vaccination  was 
performed  during  the  incubatory  period  of  small -pox. 
Perhaps  the  reason  why  may  not  be  obvious  to  all,  and 
it  will  not  be  thought  superfluous  if  it  is  more  fully  stated. 

The  history  of  Cases  24  and  37  cannot  now  be  given, 
but  that  of  362  will  serve  as  an  illustration.  The  girl, 
who  was  twenty-three  years  of  age,  had  her  face  scarred 
in  the  manner  faces  are  scarred  when  a  person  has  never 
been  vaccinated  ;  and,  moreover,  the  severity  of  the  attack 
was  further  evinced  by  her  having  lost  an  eye  through 
the  disease,  which  she  had,  as  she  stated,  when  she  was 
only  fourteen  months  old,  after  vaccination.  Upon  question- 
ing her  as  to  her  vaccination,  she  alleged  she  was  vac- 
cinated before  she  had  small-pox,  and  on  examining  her 
arms  six  large  foveated  and  well-marked  scars  of  vaccina- 
tion existed,  three  on  each  arm,  and  arranged  in  the  same 
pattern  as  my  predecessor  Mr.  Marson  was  in  the  habit 
of  placing  his  insertions  of  lymph.  From  the  appearance 
of  the  scars  I  could  not  doubt  but  they  were  done  before 
her  attack  of  small-pox.  So  much,  then,  was  all  that  could 
be  gathered  from  the  patient  herself ;  but  I  ascertained  her 
mother's  address,  and  upon  calling,  her  mother  told  me 
that  her  husband  was  seized  with  the  small  -  pox  one 
Wednesday,  and  she  took  her  children,  who  had  not  been 
vaccinated,  to  Surrey  Chapel  on  the  following  Tuesday, 
and  that  the  child  in  question  was  taken  ill  with  small-pox 
on  the  following  Saturday.  This  girl  was  therefore  vacci- 
nated on  the  seventh  day  of  the  incubatory  period  of  small- 
pox. In  connection  with  this,  the  ■  following- cases  maybe 
mentioned :    Three   children  \>\ire  vaccmateci  at  Surrey 


TahleY. 


Diagram  showing,  the  Mortality  in  London  irom  Small  Pox, Measles     Whooping  Cough. 

from  1760  to  18.90. 
1760-70  70-80  H0-9090-18V(i  Oto10  10-20  20-30  30  40  40-50  50-60  60  70  7C-80  80~90. 


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London  ~ 
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THEORY  AND  PRACTICE  OF  VACCINATION  n 

Chapel,  or,  I  should  say,  at  Victoria  Hall,  on  May  26, 
1881.  This  turned  out  to  be  on  the  ninth  day  of  the 
incubatory  period  of  small-pox  in  two,  and  the  seventh  day 
of  the  incubatory  period  in  one.  All  the  children  had 
small-pox  in  its  unmodified  form,  yet  all  the  vaccination 
places  had  taken  perfectly,  and  were  well  formed. 

The  youngest,  aged  eight,  died  of  small-pox.  The  other 
two  were  seen  again,  one  on  June  15,  1895,  and  she  then 
bore  five  scars  of  vaccination  ;  and  one  on  July  10,  1895. 
He  also  bore  five  scars  of  vaccination.  They  were  both 
much  pitted  with  the  small-pox. 

The  history  of  Case  96,  which  is  also  one  of  the  excluded 

ones,  is  the  following :  Mrs.  L.  S.  A  ,  set.  22,  states  that 

she  has  had  small-pox  twice,  the  first  attack  at  the  age 
of  two,  the  second  at  the  age  of  eleven  years.  She  said 
she  had  been  successfully  vaccinated  in  infancy,  and, 
indeed,  bore  three  well-marked  and  characteristic  scars  of 
vaccination.  She  also  said  that  seven  others,  her  brothers 
and  sisters,  all  had  the  disease  at  the  same  time,  although 
they  had  all  been  vaccinated  ;  that  they  all  recovered,  and 
that  not  one  of  them  is  pitted,  and  that  she  herself  was 
not  pitted  from  this  attack  of  small-pox.  She  states  her 
second  attack  was  at  the  age  of  eleven  years  ;  that  she  was 
sent  to  the  hospital  ship  Atlas,  and  afterwards  to  Deptford ; 
that  from  this  attack  she  was  pitted,  and  had  since  suffered 
from  disease  of  the  hip-joint  in  consequence  of  the  attack. 
If  this  history  were  true,  we  should  have  to  believe  that 
she  had  an  attack  of  small-pox  within  two  years  of  a 
successful  vaccination  done  in  three  places.  That  this 
attack  of  small-pox  did  not  take  place  during  an  epidemic 
year,  but  in  one  in  which  London  was  remarkably  free  from 
the  disease,  viz.,  in  1875.  That  not  only  she,  but  seven  of 
her  brothers  and  sisters,  all  of  whom  had  been  vaccinated 
likewise,  had  the  complaint;  nevertheless  all  recovered,  and 
not  one  of  them  was  pitted.  That  she  again  suffered  from 
the  disease  within  nine  years  of  her  alleged  first  attack. 
The  whole  history  is  so  full  of  glaring  improbabilities  that 
we  cannot  but  feel  justified  in  excluding  it  from  Table  VII. 


THEORY  AND  PRACTICE  OF  VACCINATION 


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THEORY  AND  PRACTICE  OF  VACCINATION  29 


Table  VII. 


ACl  111  1 1 X  G  (J.  1 JT 

unvaccinated. 

Stated  to 
have  been 
vaccinated, 
but  having 

no  scars. 

Having 
1  scar. 

Having 
2  scars. 

Having 
3  scars. 

4  scars. 



Having 
5  or  more 
scars. 

Days. 

Days. 

3 

3 

7 

... 

14 

21 

21 

28 

... 

35 

42 

42 

42 

42 

42 

... 

49 

61 

61 

63 

... 

90 

90 

91 

91 

106 

92 

122 

... 

122 

152 

182 

182 

182 

... 

183 

183 

... 

183 

213 

213 

274 

274 

275 

304 

OUi 

304 

335 

335 

Years. 

Years. 

1 

1 

1 

1 

1 

... 

1 

1 

j 

3° 


THEORY  AND  PRACTICE  OF 


VACCINA  TION 


Admittedly 
unvaccinated. 

Stated  to 
have  been 
vaccinated, 
but  having 

no  scars. 

Having 
1  scar. 

Having 
2  scars. 

HaviDg 
3  scars. 

Having 
4  scars. 

Having 
5  or  more 
scars. 

Years. 

Years. 

Years. 

1 

1 

1 

1*16 

1"33 

1-5 

V5 

1-5 

1-5 

... 

1*83 

1  -5 

2 

2 

2 

2 

2 

■■• 

2 

2 

2 

2 

... 

2 

2 

"' 

2 

2 

2 

2 

2 

2 

... 

2 

2 

... 

2 

2 

2 

2 

2 

2 

2'5 

2'5 

2-5 

2-5 

2'5 

2'83 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

35 

... 
... 

i 

... 

THEORY  AND  PRACTICE  OF  VACCINATION  31 


Admittedly 
un  vaccinated. 


Years. 
4 
4 
4 
4 
4 
4 
4 
4 
4 
4 

4-5 

5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
5 


Stated  to 
have  been 
vaccinated, 
but  having 

no  scars. 


Years. 
4 

4 
4 


Having 
1  scar. 


Years. 


Having 
2  scars. 


Years. 


Having  H-ing 


32         THEORY  AND  PRACTICE  OF  VACCINATION 


1 

Admittedly 
unvaccinated. 

Stated  to 
have  been 
vaccinated, 
but  having 

no  scars. 

Having 
1  scar. 

Having 
2  scars. 

Having 
3  scars. 

Having 
4  scars. 

1 

Having 
5  or  more 
scars. 

Years. 

Years. 

Years. 

Years. 

Years. 

Years. 

Years. 

/ 

7-5 

8 

8 

'8 

8 

8 

8 

8 

8 

8 

8 

8 

8 

8 

8 

8 

8 

8 
8 

8 

8 

9 

9 

9 

9 

9 

9 

9 

9 

9 

9 

9 

9 

9-5 

10 

10 

10 

10 

10 

10 

10 

10 

10 

10 

10 

10 

10 

10-5 

11 

11 

11 

ii 

11 

11 

11 

11 

11 

11-5 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

12 

13 

13 

13 

13 

13 

13 

13 

13 

13 

13 

14 

14 

13 

14 

13 

14 

14 

13 

14 

13 

14 

14 

13 

14 

14 

16 

14 

14 

13 

14 

14 

14 

14 

15 

15 

15 

15 

15 

15 

15 

15 

15 

16 

15 

15 

15 

16 

16 

16 

16 

16 

15 

15 

16 

16 

16 

16 

15 

17 

17 

17 

16 

17 

17     1  ... 

THEORY  AND  PRACTICE  OF  VACCINATION 


Stated  to 

Admittedly 
unvaccinated. 

have  been 
vaccinated 
but  having 
no  scars. 

Having 
1  scar. 

Having 
2  scars. 

Having 
3  scars. 

Having 
4  scars. 

Having 
5  or  more 
scars. 

Years. 

Years. 

Years. 

Years. 

Years. 

Years. 

Years. 

16 

17 

17 

17 

16 

16 

17 

18 

18 

17 

18 

19 

18 

19 

18 

18 

17 

19 

19 

19 

21 

19 

18 

18 

19 

19 

21 

21 

20 

19 

18 

19 

20 

22 

21 

21 

21 

18 

20 

20 

28 

22 

21 

22 

19 

20 

20 

34 

27 

22 

24 

20 

21 

21 

22 

24 

20 

21 

22 

23 

26 

22 

22 

22 

25 

29 

24 

22 

23 

26 

33 

24 

22 

25 

27 

34 

24 

26 

27 

27 

38 

24 

26 

29 

30 

25 

27 

30 

30 

27 

27 

30 

36 
36 

29 
30 
30 
30 
30 
34 
37 

28 
33 

... 

looZ 

VfDZ  D'± 

OOO 

oy-i  o 

1  oo 

210  cases, 

105  cases, 

47  cases, 

31  cases, 

33  cases, 

12  cases, 

10  cases, 

average 

average 

average 

average 

average 

average 

average 

=  6*58 

=  9-07 

=  17-77 

=  17*82 

=  18-02 

=  18-67 

=  19-3 

years. 

years. 
9-86* 

years. 

years. 

years. 

years. 

years. 

The  more  reasonable  opponents  of  vaccination  admit  the 
decrease  of  small-pox  at  the  present  time,  but  explain  the 
decrease  in  two  ways.  They  say,  first,  that  improved 
sanitary  conditions  have  occasioned  it.  We  will  admit  that 
to  a  very  limited  extent  this  is  true,  but  if  it  be  the  main 
reason  then  surely  the  other  zymotic  diseases  should  also 
have  declined  in  some  such  way  as  small-pox.  From 
Table  V.  it  will  be  seen  that,  instead  of  decreasing,  they 


*  This  lower  figure  is  the  corrected  age.    (See  p.  9.) 

3 


34        THEORY  AND  PRACTICE  OF  VACCINATION 


seem  to  have  absolutely  increased,  moreover  in  the  one 
disease,  whose  death  ages  are  analyzed  by  Dr.  Percival  in 
the  last  century,  viz.,  measles.    See  Table  VIII. 

Table  VIII. 

AGE  AT  DEATH  FROM  MEASLES  AT  MANCHESTER,  FROM  1760  TO 
1774,  COLLECTED  FROM  THE  REGISTER  OF  THE  COLLEGIATE 
CHURCH. 


Age 
0-1 

Age 
1-5 

Age 
5-20 

Age 
20-40 

Age 
40-60 

Age 
60-80 

15 
16-48 

72 
79-12 

4 
4-40 

0 

0 

0 

We  see  that  95*6  per  cent  of  individuals  who  died  of 
measles  were  under  5  years  of  age  in  the  last  century. 

Table  IX. 

AGE  AT  DEATH  FROM  MEASLES  IN  LONDON  DURING  THE  PERIOD 
1890  TO  1894. 


Age 

Age 

Age 

Age 

Age 

Age 

0-1 

1-5 

5-20 

20-40 

40-60 

60-S0 

2,747 

9,916 

751 

28 

2 

1 

20-43 

73-75 

5-59 

•21 

•02 

•007 

From  Table  IX.  we  see  that  94*18  per  cent,  deaths  from 
measles  take  place  at  the  present  day  in  children  under 
5  years  of  age ;  in  fact,  very  nearly  the  same  as  in  the  last 
century — a  very  different  state  of  things  from  what  we  have 
seen  to  be  the  case  with  small-pox. 

That  to  have  had  small-pox  in  infancy  was  as  common 
in  pre-vaccination  times  as  it  is  at  the  present  day  to  have 
had  measles  in  infancy,  may  be  inferred  from  the  condition 
of  things  in  Ware.*  At  the  time  we  are  speaking  of,  viz., 
1722,  Ware  was  only  a  village  with  a  population  of  2,515. 

*  See  a  paper  in  the  library  of  the  Boyal  Society,  England. 


THEORY  AND  PRACTICE  OF  VACCINATION  35 


The  registrar  divided  the  population  into  three  classes. 
The  first  class  contained  those  who  had  had  small-pox  in 
a  previous  epidemic.  They  numbered  1,601  cases.  The 
second  class  contained  those  who  had  small-pox  during  the 
then  present  epidemic,  and  these  numbered  612,  of  which 
72  died,  leaving  540  alive.  Therefore  there  were  living, 
after  the  epidemic,  2,443,  of  which  2,141  had  had  small- 
pox, or  88  per  cent.,  and  the  third  class  were  contained 
under  the  heading  of  those  who  have  to  have  their  small-pox. 

We  may  hence  infer  that  88  per  cent,  of  the  population 
of  Ware,  after  the  epidemic  of  1722  were  more  or  less 
pitted  with  the  small-pox.  At  the  present  time,  walking- 
through  the  streets  of  London,  we  have  counted  3,720 
people  passing  by,  and  of  these  only  9  were  obviously 
scarred,  or  '24  per  cent. 

Some  little  explanation  might  here  be  given  of  the 
methods  by  which  Table  V.  has  been  compiled,  for 
an  apparent  inconsistency  may  to  some  extent  be  ex- 
plained. 

Deaths  from  small-pox  prior  to  the  year  1838,  which  was 
the  first  year  that  the  Eegistrar-General's  Eeports  were  pub- 
lished, containing  as  they  did  certificates  of  death  from 
registered  medical  practitioners,  deaths  from  small-pox  and 
other  diseases  were  previously  collected  from  certificates 
which  the  law  compelled  to  be  given  before  the  body  of  the 
deceased  could  be  buried.  These  certificates  were  given  by 
persons  whom  the  guardians  of  the  poor  appointed.  They 
were  called  'Searchers,'  and  it  was  their  duty  to  inspect 
every  dead  body,  and  to  give  a  certificate,  as  far  as  they 
were  able,  as  to  the  cause  of  death.  These  certificates  were 
sent  weekly  by  the  parish  clerks,  who  received  them  on  the 
burial,  to  the  Company  of  Parish  Clerks,  and  this  company 
were  thus  able  to  issue  a  weekly  publication,  which  went 
by  the  name  of  the  Weekly  Bills  of  Mortality.  These  bills 
were  summarized  yearly,  and  the  summarized  bills  were 
called  the  General  Bills. 

The  '  Searchers '  were  not  medical  practitioners ;  indeed 

3—2 


36        THEORY  AND  PRACTICE  OF  VACCINATION 


they  were  often  the  poorest  people  in  the  parish,  for  it  was 
anything  but  a  pleasant  occupation  to  visit  the  bodies  of  the 
dead,  especially  those  who  had  died  of  infectious  diseases. 
The  following  quotations  from  old  authors  will  show  what 
has  just  been  stated  of  them  is  correct. 

From  John  Graunts,  F.R.S.,  Bills  of  Mortality,  published 
in  1676,  p.  34. 

'In  the  next  place  it  shall  be  examined  under  what 
name  or  cassualty  such  as  die  of  these  diseases  are 
brought  in ;  I  say,  under  the  Consumption  ;  foreasmuch  as 
all  dying  thereof  dye  so  emaciated  and  lean  (their  Ylcers 
disappearing  upon  Death)  that  the  Old-women  Searchers, 
after  the  mist  of  a  cup  of  Ale,  and  the  bribe  of  a  two 
groat*  fee,  instead  of  one  given  them,  cannot  tell  whether 
this  emaciation  or  leanness  were  from  a  Phthisis  or  from  an 
Hectick  Fever,  Atrophy,  etc.,  or  from  an  Infection  of  the 
Spermatick  parts  which  in  lenghth  of  time  and  in  various 
disguises  hath  at  last  vitiated  the  habit  of  the  Body  and  by 
disabling  the  part  to  digest  their  nourishment  brought  them 
to  the  condition  of  leanness  above  mentioned.' 

Dr.  Fothergill,  quoted  by  Willan  in  his  miscellaneous 
works,  edited  by  Ashby  Smith,  M.D.,  1821,  '  Observations 
on  the  Weather  and  Disease,'  p.  196. 

Dr.  Fothergill  was  of  opinion  that  the  number  of  deaths 
from  Consumption  was  greatly  over-rated  in  the  Bills  of 
Mortality  ;  he  remarks  on  this  subject  "  Foreigners  who 
are  ignorant  in  what  manner  our  Bills  are  compiled  give  it 
out  that  Consumption  is  the  grand  endemic  of  England. 
The  Searchers  are  commonly  two  (sic)  as  poor  and  ignorant 
persons  as  the  Parish  affords  ;  these  are  to  see  all  dead 
bodies  and  to  report  to  the  Company  of  Parish-clerks  of 
what  disease  they  died  ;  if  the  body  is  emaciated,  which 
may  happen  even  from  an  acute  fever,  it  is  enough  for 
them  to  place  it  to  the  account  of  Consumption  though  the 
death  of  the  part}7  was  perhaps  owing  to  a  disease  specifically 
different ;  and  thus  a  monstrous  account  is  framed  by  the 

*  A  groat  =  fourpence. 


THEORY  AND  PRACTICE  OF  VACCINATION  37 


ignorance  of  the  searchers,  to  the  disgrace  of  our  country 
and  even  so  far  as  to  discourage  some  foreigners  from  coming 
among  us." ' 

It  will  be  readily  inferred  how  frequent  errors  of  diagnosis 
must  have  been.  However,  the  disease  most  easily  recog- 
nised was  small-pox,  and  fewest  mistakes  would  there- 
fore be  registered  under  this  disease.  That  the  Bills  of 
Mortality  did  not  in  fact  over-estimate  the  deaths  from 
small-pox  may  be  inferred  from  the  registration  of  disease 
in  1838  and  1839,  for  we  have  the  registration  both  of  the 
Bills  of  Mortality  and  the  Registrar-General.  We  find  that 
for  1838  the  Bills  of  Mortality  give  788  deaths,  whereas  the 
Registrar- General  gives  3,817  deaths,  but  the  Registrar- 
General's  records  embrace  districts  outside  the  Bills  of 
Mortality.  Now  we  know  nearly  what  districts  outside  the 
Bills  of  Mortality  contributed.    They  were  as  follows : 

Kensington     ...       ...       ...       ...       ...  253 

Marylebone    199 

Pancras  (including  Small-pox  Hospital)    . . .  372 

Camberwell    ...       ...       ...       ...       ...  23 

Greenwich      ...       ...       ...       ...        ..  129 

One-third  of  Poplar  to  represent  St.  Leonard, 

Bromley,  and  St.  Mary,  Stratford-le-Bow. . .  23 
One-tenth  of  Hackney  to  represent  St.  Mary, 

Stoke  Newington                                ...  7 

1,006 

Hence,  if  we  deduct  this  number  from  the  Registrar- 
General's  figures,  3,817-1,006  =  2,811,  this  ought  to  tally 
with  the  number  of  deaths  recorded  by  the  Bills  of  Mortality, 
but  it  is  in  fact  2,023  in  excess,  or  the  Bills  register  257  per 
cent,  too  little  small-pox.  There  is  another  reason  to  suspect 
that  the  Bills  of  Mortality  in  London  under-estimated  the 
deaths  from  small-pox,  and  that  is,  on  referring  to  Table  V., 
p.  34,  it  will  be  seen  that  the  average  small-pox  deaths  was 
higher  in  Kilmarnock,  a  then  village  in  the  south  of  Scot- 
land, than  it  was  in  London.    As  the  registration  was  dif- 


38        THEORY  AND  PRACTICE  OF  VACCINATION 


ferent  from  what  it  was  in  London,  the  apparently  higher 
death-rate  in  Kilmarnock  may  be  more  than  accounted  for 
by  the  errors  of  registration  in  London. 

Death  is  the  worst  evil  that  can  befall  us,  but  there  is  one 
nearly  as  bad,  and  that  is  blindness.  The  blind  institutions 
of  the  last  century  used  to  receive  their  greatest  contingent 
from  unfortunate  people  who  had  lost  their  sight  from 
small-pox.  Sir  Gilbert  Blane  quoted  a  report  of  the  Hospital 
for  the  Indigent  Blind  to  the  effect  that  two-thirds  of  those 
who  applied  there  for  relief  had  lost  their  sight  by  small- 
pox.* 

Dr.  Gregory,  the  superintendent  of  the  Small-pox  Hospital 
in  1819,  writes,  that  a  large  proportion  of  the  blind  have 
been  found  to  owe  their  misfortune  to  the  secondary  fever  of 
small-pox. 

Mr.  Cross,  writing  of  the  epidemic  of  small-pox  at  Norwich 
in  1819,  states  that  of  200  cases  of  small-pox,  3  had  lost 
eyes  from  small-pox,  or  1*5  per  cent. 

In  the  present  day,  a  statement  of  the  Christian  Blind 
Belief  Society  (established  in  1843)  contains  the  names 
of  fifty  people  seeking  relief,  blind  from  all  causes.  One 
of  these  people  was  blind  from  having  had  small-pox, 
viz.,  Sarah  Barnes,  Bethnal  Green,  aged  39.  Small-pox 
hence  appears  to  occasion  2  per  cent,  of  the  blindness  at 
the  present  time.  The  date  of  the  advertisement  is  about 
1888.    A  copy  of  the  statement  is  appended,  p.  39. 

Dr.  Brailey  has  also  noticed  the  vaccination  scars  of 
fifteen  cases  of  people  who  had  lost  an  eye  from  small-pox, 
and  he  found  that  seven  were  admittedly  unvaccinated  when 
they  had  the  small-pox  which  blinded  them.  These  cases 
were  16  out  of  763  who  lost  eyes  from  all  causes,  which 
shows,  as  far  as  it  goes,  that  2*24  per  cent,  of  the  blindness 
at  the  present  time  is  caused  by  small-pox.    (See  p.  40.) 

*  Medico-Chirurgical  Transactions,  vol.  x.,  p.  826. 


THEORY  AND  PRACTICE  OF  VACCINATION 


J) 


Statement  of  the  Christian  Blind  Belief  Society. 


Candidates. 


1.  Mitchell,  Wm.  H.  ... 

2.  Smith,  Stephen 

3.  Brady,  Elizabeth 

4.  Sandiforth,  Harriett . . . 

5.  Rham,  Elizabeth 

6.  Ballinger,  Harriett  ... 

7.  Barnes,  Sarah  ... 

8.  Willard,  Richard 

9.  Lamb,  Mary  ... 

10.  Chatfield,  Albert  Edw. 

11.  Brown,  John  ... 

12.  Bayley,  Charlotte 

13.  Wilkinson,  James 

14.  Berry,  Ellen  

15.  Perrigo,  Francis 

16.  Harding,  Thos. 

17.  Goodchild,  Augusta  . 

18.  Savage,  Christopher  .. 

19.  Lee,  Alice  A.  H. 

20.  Hadkinson,  Eliz. 

21.  Kelynack,  Charlotte  .. 

22.  Lucas,  Grace  ... 

23.  Bush,  Fanny  ... 

24.  Edwards,  Edith 

25.  Franks,  Hy.  Wm. 

26.  Dutnall,  Mary  A. 

27.  Cadman,  Eliza 

28.  Winterton,  Geo. 

29.  Burley,  Wm  

30.  Walker,  Maria 

31.  Hay  ward,  James 

32.  Smith,  Eliz  

33.  Ponshaw.  Hy. 

34.  Puddefoot,  Daniel  .. 

35.  Flipping,  Emma 

36.  Silvester,  Emma 

37.  Poynter,  Emily 

38.  Parkes,  John  ... 

39.  Jennings,  Geo. 

40.  Smith,  James  ... 

41.  Jaggers,  Thomas 

42.  Brookes,  Thos. 

43.  Bennett,  Alfred 

44.  •Gaylor,  Susan  .. 

45.  Lawrence,  Sarah 

46.  Nicholes,  Wm. 

47.  Brassington,  H. 

48.  Foster,  Emma 

49.  McCullum,  Fanny  . 

50.  Cosker,  Thos  


Age. 

Address. 

Cause  of  Blindness. 

56 



Westerntown,  Sidmouth 



Disease  of  brain. 

80 

St.  Leonard's-on-Sea  ... 

Cataract. 

36 

Darlington 

Inflammation. 

33 

Kippax,  Leeds  ... 

Glaucoma. 

46 

Wisbeach 

Detachment  of  retina. 

48 

Minsterworth 

Cataract. 

39 

Bethnal  Green  ... 

Small-pox.* 

74 

Silverhill,  Hastings 

Cataract. 

64 

Shepherd's  Bush 

Cataract. 

51 

Stoke-on-Trent  ... 

Fits  in  infancy. 

62 

Norwich  ... 

Inflammation. 

67 

Tottenham  Court  Road. , . 

Cataract. 

55 

Kentish  Town  ... 

Typhus  fever. 

43 

Drury  Lane 

Typhus  fever. 

78 

Leominster 

Cataract. 

84 

Dursley,  Gloster 

Unknown. 

39| 

Wells,  Somerset 

Disease  of  bram. 

56 

St.  Luke's,  E.C. 

Yellow  fever. 

20 

Mile  End   

Measles. 

51 

Battersea 

Effects  of  a  blow. 

32 

Penzance... 

Illness. 

68 

Haggerston 

Cataract. 

46 

Chichester   

Constitutional. 

25 

Chelsea  ... 

Atrophy  of  the  nerves. 

28 

Canterbury   

Born  blind. 

53 

Maidstone 

Inflammation. 

45 

Wolverhampton 

Cataract. 

65 

Ware 

Cataract. 

32 

S.  Lambeth 

Failing  of  optic  nerve. 

71 

Maida  Vale   

Glaucoma. 

53 

Ryde,  I.W  

Constitutional. 

19 

Abbenhall 

Hereditary. 

35 

Southampton 

Water  on  the  brain. 

69 

Hemel  Hempstead 

30 

Camden  Town  ... 

Tumour  on  the  brain. 

43 

Bristol   

Abscess  on  brain. 

39 

Orleton  ... 

Inflammation. 

46 

Stoke  Ferry   

Disease  of  nerve. 

38 

Bow   

Cold. 

50 

Newmarket 

Scrofula. 

33 

Barking  

Born  blind. 

42 

E.  Greenwich  ... 

Lead  colic. 

35 

Bethnal  Green  

Constitutional  weak- 

ness. 

.  39 

Hatfield  

Born  blind. 

.  55 

Preston  ... 

Disease  of  the  optic 

nerve. 

.  50 

Poplar 

Retina  destroyed. 

.  58 

Leek 

Inflammation. 

.  72 

Stratford  

Unknown. 

.  43 

Poplar   

Weakness. 

.  73 

Limehouse 

Sudden  strain. 

*  Showing  that,  according  to  this  statement,  small-pox  even  now  occasions 
2  per  cent,  of  the  whole  total  blindness. 


THEORY  AND  PRACTICE  OF  VACCINATION 


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LECTURE  II. 


HISTOLOGY  OF  THE  VACCINE  AND  SMALL-POX  VESICLES. 

To-day,  gentlemen,  I  have  to  call  your  attention  to  the 
morbid  anatomy  of  vaccinia  and  to  that  of  small-pox,  and  I 
hope  to  establish  in  your  minds  the  close  anatomical  changes 
which  hold  between  these  morbid  conditions — in  fact,  I 
may  say,  establish  their  identity  so  far  as  their  morbid 
anatomy  is  concerned.  I  shall  also  step  over  our  strict 
boundary  to  say  a  few  words  about  the  morbid  anatomy  of 
chancre,  and  I  hope  to  be  able  to  show  you  how  utterly 
different  are  the  minute  changes  which  take  place  during 
the  development  of  the  syphilitic  chancre.  I  should  not 
have  alluded  to  this  last-mentioned  disease  if  it  had  not 
been  recently  affirmed  by  a  gentleman,  who  is  essentially  an 
anti-vaccinator,  though,  I  believe,  he  does  not  admit  as 
much.  Dr.  Crighton  is  referred  to.  He  implies  that  every 
vaccination  vesicle  is  a  lesion  of  a  syphilitic  nature. 

Before  we  enter  upon  a  discussion  of  the  morbid  changes 
which  take  place  after  vaccination,  it  may  be  convenient  to 
review  the  normal  histology  of  the  special  seat  of  lesion, 
viz.,  the  skin,  and  I  shall  adopt  Dr.  Klein's  nomencla- 
ture. 

First,  then,  we  find  the  external  cuticle,  epidermis,  or 
scarf-skin ;  this  layer  is  called  by  Klein  the  stratum  corneum. 
(See  Plate  I.,  a.)  It  is  that  portion  of  the  skin  which  is 
raised  from  the  rest  when  a  blister  is  applied.    It  is  also 


42         THEORY  AND  PRACTICE  OF  VACCINATION 

that  part  which  becomes  detached  when  the  dead  skin  is 
macerated,  as  when  the  body  of  a  man  has  been  in  water  a 
week  or  two,  or  the  foetus  has  suffered  intra-uterine  death  and 
not  been  shortly  expelled.  Immediately  below  this  may  be 
seen  the  stratum  lucidum ;  it  is  a  thin  homogeneous  layer, 
the  component  cells  of  which  are  only  indistinctly  seen  in 
some  sections,  and  the  nuclei  have  disappeared.  (See 
Plate  L,  b.) 

The  next  layer  is  the  granular  layer  of  the  rete  Malpighii 
(Langerhaus).  It  consists  of  flattened  cells,  with  a  nucleus 
and  granules.  The  granules  are  chiefly  to  be  seen  at  the 
poles  of  the  nucleus,  gradually  diminishing  in  size  as  they 
extend  outwards.    (See  Plate  I.,  c.) 

The  next  layer  of  the  rete  Malpighii  (see  Plate  L,  d.)  is 
a  more  or  less  stratified  layer,  of  which  the  more  superficial 
cells  are  flattened  together  with  their  nuclei.  In  the  suc- 
ceeding layers  the  cells  and  their  nuclei  are  rounder.  The 
cells  are  connected  with  each  other  by  fine  filaments,  the 
so-called  prickle  cells  (Max  Schultze).  (See  Plate  L,  a, 
Fig.  2.)  Lastly,  in  the  deepest  layer  the  cells  are  columnar, 
with  oval  nuclei.  These  latter  rest  upon  the  cutis  vera  or 
corium.    (See  Plate  I.,  e.) 

Thus  far  only  need  we  minutely  describe  the  epidermis. 
The  pathological  changes  which  take  place  after  a  success- 
ful vaccination  are :  first,  there  is  an  increase  of  intercellular 
fluid,  especially  between  the  round  epithelial  cells  of  the 
rete  Malpighii,  probably  on  account  of  this  increase  of  the 
fluid  or  nourishing  material ;  you  have  an  increased  forma- 
tion of  cells,  and  an  increase  in  size  of  individual  cells. 
These  three  increases,  viz.,  the  increase  of  the  intercellular 
fluid,  the  increase  in  the  formation  of  cells,  and  the  increase 
in  size  of  many  of  the  cells,  together  constitute  the  hard 
red  papule,  which  feels  like  a  shot  underneath  the  skin. 
This  stage  is  called  the  papular  stage.  The  papule  grows 
in  area,  encroaching  more  and  more  on  the  healthy  skin 
centrifugally,  while  in  the  centre,  owing  to  the  large  amount 
of  intercellular  fluid  and  the  rupture  of  some  of  the  large 


PLATE  I 


Z.  Strcuturrv  TjuaxloLuwo. 

3,  Svope^fLcLoiL  layer  of  reie-  malp hg "hvuL  irixduxLuruj  grocruxLocr  oell 
layer. 

4-,  MvcLdLe-  Zccyei-  o  f  -rate-  mxikp  i^g  InAx-. 
5>D&ep  layer*  of  do. 


Homdredtks  and  Tentlas  of  a.  Millimetre 


West,  l\f e v» man  clrromo . 


PLATE'  la,. 


PLATE  II 


West,lTewman.  cTaromo 


HISTOLOGY  OF  THE  VACCINE  DISEASE  43 


cells,  vacuoles,  as  they  have  been  called,  are  formed.  They, 
however,  are  full  of  the  vaccine  lymph.  (See  Plate  L,  a, 
Fig.  3.)  Some  of  the  cells  do  not  burst,  but  are  more  or 
less  distorted  from,  pressure  and  tension,  becoming  spindle- 
shaped.  These  elongated  cells,  lying  in  juxtaposition  with 
one  another,  form  the  walls  of  the  vacuoles,  and  are,  in  fact, 
the  dissepiments  of  the  vesicle,  for  the  vaccine  vesicle  is  not 
like  a  pustule,  from  which,  when  pricked  in  one  place,  all  the 
pus  can  be  extracted  from  this  one  opening.  Not  so,  however, 
the  vaccine  vesicle  ;  for  this  must  be  pricked  in  many  places, 
on  account  of  these  dissepiments,  before  much  lymph  can 
be  obtained.  The  vaccine  vesicle  is  more  of  a  honeycombed 
structure  rather  than  a  pouch.  (See  Plate  L,  a,  Fig.  3.) 
These  changes  take  place  first  at  the  site  of  vaccination, 
and,  as  I  have  said,  gradually  extend  outwards,  the  newly- 
invaded  portion  of  the  skin  going  through  the  same  changes 
as  did  that  of  the  centre  ;  but  as  the  vesicle  extends  outwards 
other  changes  take  place  at  the  centre.  The  vacuoles  here, 
at  first  large,  become  smaller,  cell  growth  ceases,  and  the 
enlarged  cells  begin  to  shrink,  so  that  if  a  section  be  made 
at  this  stage  of  the  vesicle's  growth  on  a  plane  parallel  with 
the  surface  of  the  skin,  it  will  have  the  appearance  repre- 
sented in  Plate  II. 

The  ordinary  description  of  the  vesicle  consisting  of 
radiating  dissepiments,  like  those  of  an  orange,  is  quite 
imaginary,  for  there  is  really  no  regularity  about  their 
deposition.  It  is  true  the  vacuoles  in  the  centre,  or  those 
which  were  first  formed,  are  smaller,  from  absorption 
of  the  fluid,  than  the  later  formed  ones  at  the  circum- 
ference, and  this  may  have  given  systematists  the  idea  that 
the  vesicle  consists  of  radiating  divisions.  And,  further,  the 
puckered  condition  of  some  vaccine  scars  may  have  confirmed 
this  impression ;  but  the  puckering  of  the  scar,  when  it  exists, 
is  not  from  the  remains  of  these  fanciful  radiating  dissepi- 
ments, but  from  the  severity  of  the  inflammatory  progress 
of  the  disease,  the  whole  thickness  of  the  skin  having  been 
involved,  and  the  consequent  contraction  of  the  resulting 


44        THEORY  AND  PRACTICE  OF  VACCINATION 


cicatrix.  The  formation  of  these  vacuoles,  as  we  have 
described,  continues  until  the  vesicle  has  finished  enlarging, 
and  this  stage  of  the  development  of  the  vesicle  we  may 
call  the  vesicular  stage.  Before,  however,  the  vesicle  has 
quite  ceased  to  grow,  an  inflammation  of  the  skin  adjacent 
to  the  vesicle  begins  to  appear,  first  immediately  round  the 
vesicle,  and  generally  extends  when  at  its  height  to  more 
than  an  inch  in  extent  around  the  vesicle.  This  inflamma- 
tion or  areola,  as  it  is  called,  usually  begins  early  on  the 
eighth  day,  and  may  begin  earlier  if  the  vesicle  be  advanced, 
or  later  if  the  vesicle  be  retarded,  or  may  even  scarcely  appear 
at  all,  if  the  child  has  taken  mercury  some  days  before  and 
continues  taking  it  during  the  course  of  vaccination.  Hence, 
a  total  absence  of  all  areola  on  the  eighth  day  is  to  be 
looked  upon  with  suspicion.  This  areola  is  at  its  height  on 
the  tenth  day  after  primary  vaccination,  and  then  begins  to 
decline.  At  this  stage  of  the  vesicle  a  second  or  new  stratum 
lucidum  begins  to  form  (Plate  III.,  c),  at  first  at  the  margins 
of  the  vesicle,  and  subsequently  over  its  whole  area.  The 
old  stratum  lucidum  forms  the  external-limiting  membrane 
of  the  vesicle,  for  the  stratum  corneum  is  generally  shed 
and  separates  from  the  stratum  lucidum,  leaving  this,  as 
we  have  already  said,  the  external  limiting  membrane. 
The  new  stratum  lucidum  forms  over  the  bottom  of  the 
vesicle.  It  is  really  the  beginning  of  the  process  of  heal- 
ing, and  is,  in  fact,  the  first  formation  of  the  new  skin 
beneath  the  vesicle,  and  all  the  tissues  between  the  two 
strata  lucida  dry  up  and  constitute  the  thick  dark  scab 
which  forms  over  the  site  of  vesiculation.  This  is  the  reason 
why,  after  vaccination,  the  scab  that  forms  is  so  thick. 

If  nothing  is  placed  on  the  wound  to  prevent  the  scab 
drying  up  as  it  naturally  should,  and  the  healing  process 
goes  on  uninterruptedly,  then  when  the  primary  scab  falls, 
which  it  normally  does  on  the  twenty-first  day  after  vaccina- 
tion, a  sound  surface  to  the  previously  diseased  skin  presents 
itself ;  but  if  the  primary  scab  should  be  removed  by  a 
poultice  or  other  means  before  the  process  of  healing  has 


PLATE  III 


Tenths  and  Hundredths  of  a  Millimetre  x!12. 


HISTOLOGY  OF  THE  VACCINE  DISEASE  45 


sufficiently  taken  place,  then  a  moist  surface  remains 
through  which  the  humours  of  the  body  find  exit,  and 
drying,  by  reason  of  the  warmth  of  the  body,  secondary 
sulphur  scabs  form  in  the  place  of  vesiculation,  and  if 
these  be  removed  by  poultice  an  ulcerated  place  is  found. 
This  ulceration  may  extend  a  considerable  depth,  even  right 
through  the  skin.  This  condition  is  more  often  seen  when 
the  vesicles  have  been  subjected  to  maltreatment  after 
vaccination  with  animal  lymph  than  it  is  after  like  mis- 
treatment with  human  lymph,  although  I  have  seen  similar 
conditions  after  the  use  of  either.  The  rule  for  treatment, 
therefore,  is  never  to  apply  a  poultice  or  wet  or  oiled  rag 
until  the  normal  areola  has  abated,  which  it  normally  does 
during  the  second  week.  If  the  primary  scab  has  been  re- 
moved either  by  maltreatment  or  otherwise,  and  the  wound 
is  covered  by  the  secondary  sulphur  scabs,  then  a  poultice 
may  be  applied  to  remove  these — a  warm  bread-poultice  is 
the  best — and  after  this  removal  a  piece  of  clean  linen  rag, 
on  which  is  lightly  spread  some  zinc  ointment,  may  be 
applied  to  the  wound.  This  should  be  changed  every 
morning  and  night.  Mercurial  ointments  should  not  be 
used  :  they  almost  invariably  irritate  the  wound  and  thus 
prevent  its  healing.  Let  me  also  here  caution  you  against 
the  use  of  '  vaccination  shields ' ;  these  might  be  proper  if 
changed  once  a  day,  but  otherwise  they  may  become  soiled 
with  the  discharges  from  the  vesicle  and  are  replaced  with 
all  their  filth  day  by  day ;  and,  moreover,  the  uneducated 
class  lend  their  shields  to  one  another,  and  if  not,  put  them 
by  for  a  future  occasion.  What  is  more  likely  to  produce 
septicaemia  than  the  use  of  such  articles?  It  is  well  to 
cover  the  part  with  a  dry,  clean  linen  rag,  and  to  change  it 
once  or  twice  a  day. 

Now,  the  minute  morbid  anatomy  of  the  skin  when 
affected  by  small -pox  is  exactly  as  I  have  described  it 
when  vaccinated.  You  have  the  same  stages  of  papula- 
tion, of  vesiculation,  and  inflammation,  and  the  same 
structures  affected.   (See  Plate  IV.)  The  small-pox  vesicle  is 


46 


THEORY  AND  PRACTICE  OF  VACCINATION 


generally  umbilicated  in  the  centre  (see  Plate  IV.,  Fig.  1), 
and  a  hair  follicle  usually  is  present  at  the  centre  of  this  urn- 
bilication,  as  seen  in  Plate  IV.,  Fig.  1.  Some  have  been  led 
to  think  that  the  hair  follicle  is  the  cause  of  the  umbilication. 
There  are  several  reasons,  however,  why  we  should  hesitate 
to  accept  this  explanation.  First,  because  the  umbilication 
takes  place  also  in  those  parts  of  the  skin  which  have  no 
hair  follicles,  e.g.,  the  palms  of  the  hands  and  soles  of  the 
feet.  Secondly,  because  a  vesicle  never  has  more  than  a 
single  umbilication,  although  covering  an  area  having  a 
plenitude  of  hair  follicles.  Thirdly,  in  inoculated  small- 
pox it  is  the  site  of  the  initial  inoculation  which  forms  the 
umbilication,  and  if  the  inoculation  be  done  in  a  line  the 
umbilication  of  the  inoculated  vesicle  forms  in  the  centre 
of  this  elongated  vesicle. 

We  are  therefore  led  to  think  that  the  hair  follicle  really 
is  not  the  cause  of  the  umbilication.  The  reason  probably 
will  be  found  in  the  fact  that  the  capillaries  round  the  hair 
follicles  are  a  little  smaller  than  in  other  parts  of  the  skin, 
and  thus  the  germs  of  the  disease  are  arrested  in  them 
more  frequently.  They  thus  form  the  centres  from  which 
the  vesiculation  takes  place,  and  correspond  with  the  centre 
from  which  the  inoculated  vesicle  arises.  This  view  will 
also  help  to  explain  why  in  small -pox  you  occasionally  get 
more  numerous  vesicles  over  those  parts  where  there  is 
constant  pressure  before  patients  take  to  the  incumbent 
position  in  bed.  I  have  seen  a  distinct  line  of  vesicles  just 
below  the  knee  on  a  woman.  This  was  the  part  where  she 
used  to  wear  her  garter.  I  have  also  seen  the  same  con- 
dition on  a  man's  shoulders,  two  strips  of  more  closely 
placed  vesicles  where  the  pressure  of  the  braces  has  been. 

The  microscopical  appearance  of  the  skin  of  the  arm, 
due  to  the  morbid  condition  set  up  by  the  development  of 
a  syphilitic  chancre,  is  entirely  different  from  that  I  have 
just  described  as  due  to  vaccine.  No  vesiculation  takes 
place  either  of  the  middle  layer  of  the  rete  Malpighii,  or, 
indeed,  any  vesiculation  at  all.    There  is  a  great  prolifera- 


PLATE 


IV. 


HISTOLOGY  OF  THE  VACCINE  DISEASE 


tion  of  small  cells,  which  are  best  seen  in  the  cutis  vera 
and  in  the  tissue  immediately  below  this.  These  increase 
in  number,  extending  upwards,  and  seem  to  crowd  out  the 
normal  cells  of  the  rete  Malpighii  until  they  reach  the 
surface.  The  stratum  corneum  becoming  detached  from 
its  normal  bed,  strips  off,  and  you  thus  have  left  a  secret- 
ing surface  formed  of  the  small  round  cells  which  have 
crowded  out  the  normal  cells  of  the  rete  Malpighii.  From 
the  micro-photograph  (Fig.  2,  Plate  IV.)  it  may  be  judged 
how  entirely  different  this  morbid  process  is  to  that  which 
occurs  after  vaccination.  See  Fig.  3,  Plate  IV.  To  borrow 
terms  from  botanical  science,  we  might  describe  the  syphi- 
litic chancre  as  an  endogenous,  and  the  vaccine  vesicle  as 
an  exogenous,  growth.  Hence  we  see  the  chancre  and  the 
vaccine  vesicle  have  not  even  an  anatomical  relation.  The 
only  one  they  indeed  have  is  linguistic,  for  one  is  called  the 
small-pox  and  the  other,  in  common  parlance,  is  called  the 
great-pox.  If  this  be  the  association  of  thought,  it  recalls 
to  our  mind  the  doctrine  of  signatures  of  the  last  century. 
One  example  will  suffice  to  explain  this.  The  white 
meadow  saxifrage  (Saxifraga  granulata),  with  its  kidney- 
shaped  leaves  and  their  peculiar  spotted  surface,  has  a  sort 
of  likeness  to  the  human  lung ;  therefore  the  physicians  of 
that  day  considered  it  a  curative  for  lung  diseases,  accord- 
ing to  the  then  prevailing  doctrine  that  plants  which  repre- 
sented in  some  sort  of  fashion  various  organs  of  the  body 
were  good  for  the  disease  of  those  organs  they  were  sup- 
posed to  resemble.  This  theory  was  called,  therefore,  '  the 
doctrine  of  signatures.' 


LECTURE  III. 


THE  DIFFERENCE  BETWEEN  A  PRIMARY  AND  A  SECONDARY 
VACCINATION. 

We  will  now  consider  the  difference  between  a  primary 
vaccination  and  re-vaccination. 

Let  us  consider  a  primary  vaccination  represented  by  a 
straight  line.  At  one  end  of  the  line  we  will  suppose  that 
we  are  not  as  yet  vaccinated,  and  this  point  we  will  mark 
as  zero ;  at  the  other  end  of  the  line  we  will  suppose  that 
we  are  fully  vaccinated,  and  this  point  we  will  mark  9. 
Let  us  now  divide  the  line  0  to  9  into  nine  equal  parts, 

I  I  I  I  I  I  J  I  I  I 

012345  6789 

so  that  each  division  may  represent  the  amount  of  modi- 
fication the  system  undergoes  during  each  day  of  vaccina- 
tion. 

We  have  performed  the  two  following  experiments,  which 
we  will  detail  here,  as  they  will  help  us  to  understand  the 
appearances  of  re- vaccinations. 

The  first  experiment  was :  instead  of  putting  all  the 
vesicles  on  the  arm  at  the  time  we  first  vaccinated  it, 
we  have  put  on  only  one ;  the  next  day  we  put  on  another, 
and  so  on  until  the  tenth  day,  and  in  both  cases  which 
we  had  the  opportunity  of  so  vaccinating  we  found  that  the 
ninth  day  was  the  last  day  we  could  produce  any  specific 
effect  from  the  vaccination.     It  was  curious  to  observe 


PRIMARY  AND  SECONDARY  VACCINATION  49 

how  the  vesicles  that  were  subsequently  put  on  to  the  first 
developed.  We  will  take  that  vesicle  which  was  vaccinated 
four  days  after  the  first  as  an  example.  This  vesicle 
arrived  at  its  maturity  five  days  after  it  had  been  in- 
oculated, or  on  the  ninth  day  from  when  the  first  had  been 
inoculated.  Moreover,  it  hurried  through  its  stages,  over- 
taking gradually  the  first  vesicle,  and  both  maturing 
together  on  the  ninth  day.  That  vesicle  which  was  in- 
oculated on  the  seventh  day  reached  its  maturity  also  on 
the  ninth  day  from  when  the  first  vesicle  was  inoculated, 
or  the  second  day  from  which  it  had  been  inoculated — in 
fact,  all  the  vesicles  matured  on  the  ninth  day  from  which 
the  first  had  been  inoculated.  After  the  ninth  day  no 
further  specific  effect  could  be  produced  by  inoculation  of 
vaccinia. 

M.  Trousseau,  on  p.  121,  vol.  i.,  of  his  fourth  edition  of 
'  Clinique  Medicale,'  describes  himself  as  having  made 
similar  experiments  with  the  same  results,  and  we  know 
from  Mr.  Bryce  as  long  ago  as  1809  that  this  phenomenon 
had  been  observed,  for  on  p.  173  of  his  book  the  following 
passage  will  be  found  :  '  That  if  during  the  regular  progress 
of  cow-pox  a  second  inoculation  be  performed  a  certain 
number  of  days  after  the  first,  the  affection  produced  by 
this  second  inoculation  will  be  accelerated  in  its  progress 
so  as  to  arrive  at  maturity,  and  again  fade,  at  nearly  the 
same  time  as  the  affection  arising  from  the  first  inocula- 
tion, and  that  this  will  take  place  although  the  constitu- 
tional affection  be  so  slight  as  otherwise  to  pass  unnoticed.' 
In  passing  we  may  observe  also  that  the  same  observation 
had  been  made  with  regard  to  the  vesicle  produced  by  the 
inoculation  of  small -pox  —  another  piece  of  undesigned 
evidence  of  the  close  affinity  of  the  two  diseases.  See  p.  159, 
et  seq.,  '  Practical  Observations  on  the  Inoculation  of  Cow- 
pox,'  by  James  Bryce,  published  in  1809. 

The  second  experiment  was  :  supernumerary  fingers  were 
vaccinated  on  the  tip,  and  the  finger  removed  on  different 
days  after  vaccination. 

4 


5o         THEORY  AND  PRACTICE  OF  VACCINATION 


For  instance,  one  child  was  vaccinated  on  the  tip  of  its 
finger,  and  the  finger,  together  with  the  vaccine  vesicle, 
was  removed  on  the  fourth  day  from  the  time  it  had  been 
vaccinated.*  About  a  month  after  the  child  was  again 
vaccinated  on  the  arm.  The  second  vaccination  ran  rapidly 
through  its  course,  reaching  its  maturity  on  the  fifth  day, 
and  then  began  to  decline.  And  it  was  further  found  in 
other  children  who  had  supernumerary  fingers  that,  if  the 
finger  with  the  vaccine  vesicle  was  removed  on  the  second 
day  after  vaccination,  then  the  subsequent  vaccination  per- 
formed a  month  after  the  stump  had  healed  ran  seven  days' 
course.  In  the  former  case  four  and  five  make  nine,  and 
in  the  latter  two  and  seven  make  nine.  All  the  super- 
numerary fingers  obeyed  the  same  law,  which  was  that, 
on  the  assumption  the  vesicle  took  nine  days  to  mature, 
the  sum  of  the  times  of  the  two  vaccinations  always  equalled 
nine  days.  Let  us  look  at  the  subject  in  a  different  light. 
We  will  suppose  that  during  the  growth  of  the  vesicle  a 
certain  product  is  given  off  from  .  it,  and  that  when  the 
system  is  saturated  with  this  product,  it  is  rendered  in- 
capable of  further  supporting  the  vesicle,  therefore  the 
disease  terminates  ;  but  if  we  remove  the  vesicle  before  this 
saturation  has  taken  place  there  remains  something  short 
of  saturation,  which  condition  is  not  incompatible  with  a 
further  growth  of  the  vesicle.  Hence,  if  the  vesicle  should 
be  removed  at  any  time  before  its  full  development,  there 
will  remain  in  the  system  a  capacity  of  a  vesicle  growing 
until  saturation  occurs.  As  we  wish  this  idea  to  be  fully 
realized,  let  us  look  at  it  from  still  a  different  point.  We 
will  suppose  the  vesicle  to  consist  of  nine  definite  concentric 
circles,  one  circle  for  each  day's  growth,  and  that  each 
circle  is  inoculated  by  its  interior  adjacent  circle.  Now, 
if  we  remove  the  vesicle  before  its  full  development,  then, 
prima  facie,  there  must  remain  so  many  circles  to  be  com- 
pleted before  saturation  occurs.   In  other  words,  by  removal 

*  Paper  by  the  author  in  the  Transactions  of  the  Epidemiological 
Society,  vol.  iv.,  p.  197,  for  the  years  1875-81. 


PRIMARY  AND  SECONDARY  VACCINATION  51 

of  the  vesicle  we  prevent  further  auto-inoculation,  and  so 
all  further  diseased  action  ceases  until  we  inoculate  another 
portion  of  the  skin.  The  vesicle  will  then  proceed  with  its 
growth,  not,  indeed,  from  the  beginning,  but  from  the  time 
it  had  been  arrested,  and  so  finish  its  growth. 

Before  going  on  with  the  immediate  subject-matter  of 
this  chapter,  we  will  consider  another  very  remarkable  fact, 
for  it  has  its  bearing  upon  what  we  are  now  considering. 
It  is  this  :  if  we  use  lymph  which  has  become  inert  by  having 
been  kept  too  long  to  produce  a  vaccine  vesicle,  yet  we 
do  produce  a  certain  effect  upon  the  individual  we  vaccinate 
with  such  lymph.  This  influence  we  can  see  if  we  again 
vaccinate  successfully  the  individual,  for  the  subsequent 
vaccination  always  runs  a  slightly  accelerated  course.  The 
areola  is  thus  very  pronounced  on  the  eighth  day.  Now, 
what  reason  can  be  given  for  this  behaviour  of  the  sub- 
sequent vaccination  ?  This  is  the  one  we  offer.  V accine 
lymph  may  be  considered  to  be  composed  of  two  parts — 
one  the  living  organism,  the  other  the  product  of  the  living 
organism  which  we  assume  to  be  the  modifying  agent. 

When  we,  therefore,  vaccinate  an  individual  with  lymph 
that  has  lost  its  vitality  from  age,  we  only  introduce  a  small 
portion  of  the  product  that  has  been  already  formed.  No 
fresh  amount  of  product  can  be  formed,  as  the  organism 
which  produces  it  is  dead,  and  therefore  no  vesicle  is 
formed,  and  only  a  very  slight  modification  of  the  system 
is  produced  in  the  individual  so  vaccinated — a  modification 
which  declares  itself  in  the  slightly  shortened  course  run 
by  subsequent  vaccination  when  a  vesicle  is  produced. 
This  consideration  will  point  to  a  means  of  so  vaccinating 
an  individual  that  he  may  become  after  repeated  inocula- 
tions with  aged  lymph  insusceptible  of  further  vaccination 
without  his  ever  having  had  a  vaccine  vesicle  ;  indeed,  this 
seems  to  us  a  possible  explanation  of  the  only  case  of 
insusceptibility  we  have  ever  met  with  in  over  61,000 
cases.  The  child  referred  to  was  ten  years  old  ;  its  mother 
stated  that  vaccination  had  failed  on  previous  occasions. 

4—2 


52        THEORY  AND  PRACTICE  OF  VACCINATION 


We  failed  twice  running,  but  did  not  get  the  opportunity 
of  trying  a  third  time.* 

Let  us  suppose  that  a  person  once  efficiently  vaccinated 
has  proceeded  from  0  on  our  imaginary  line  to  9 ;  that 
there  is  a  tendency  to  return,  and  that  the  retrograde 
journey  may  be  quick  or  slow.  We  are  acquainted  with 
some  of  the  conditions  that  influence  the  return  journey, 
and  we  will  name  those  we  know  at  once,  viz.,  the  number 
of  places  a  person  is  primarily  vaccinated  in. 

In  a  considerable  number  of  persons  only  vaccinated  in 
one  place,  their  return  journey  is  quicker  than  if  they  had 
been  vaccinated  in  four  or  more.  We  base  our  assertion 
upon  the  following  evidence  : 

Mr.  Marson,  formerly  the  Medical  Officer  of  the  Inocula- 
tion and  Small-pox  Hospital  at  Highgate,  published  the 
following  table,  contained  in  a  paper  which  he  wrote  as  an 
article  on  small-pox  published  in  the  Medico-Chirurgical 
Society  Transactions,  vol.  xxxvi. 


Cases  of  small-pox,  classified  according  to  the  vaccination-marks 
borne  by  each  patient  respectively. 

Number  of  deaths 
per  cent,  in  each 
class  respectively. 

1.  Stated  to  have  been  vaccinated,  but  having  no 

cicatrix... 

21f 

2.  Having  one  vaccine  cicatrix 

7£ 

3.  Having  two  vaccine  cicatrices  ... 

4.  Having  three  vaccine  cicatrices  ... 

If 

5.  Having  four  or  more  vaccine  cicatrices 

Unvaccinated  ...   

351 

In  compiling  this  table,  Marson  deducted  the  cases  where 
a  person  not  only  died  of  small- pox,  but  also  of  some  super- 
added disease ;  but  he  gives  the  number  he  so  deducted, 
so  for  our  purpose  we  may  add  these  to  his  figures,  and 
recast  the  percentages.  This  being  done,  we  obtain  the 
following  number : 

*  Eeport  of  the  Medical  Officer  of  the  Local  Government  Board  for 
1887,  seventeenth  annual  report,  p.  28. 


PRIMARY  AND  SECONDARY  VACCINATION  53 


Cases. 

Deaths. 

.M  ortality 
per  cent. 

Unvaccinated 

2,654 

996 

37-2 

Stated  to  have  been  vaccinated,  but 

having  no  cicatrix  ... 

290 

74 

25-5 

Having  one  vaccine  cicatrix 

1,357 

125 

9-2 

Having  two  vaccine  cicatrices  ... 

888 

53 

5-9 

Having  three  vaccine  cicatrices 

274 

10 

36 

Having  four  or  more  vaccine  cicatrices 

268 

3 

11 

Dr.  Gayton,  late  Medical  Superintendent  of  the  Homerton 
Small-pox  Hospital,  has  also  published  some  10,403  cases 
of  small-pox,  noting  also  the  number  of  scars  of  primary 
vaccination  on  those  who  had  been  vaccinated.  Subjoined 
are  his  figures.  It  is  to  be  understood  that  Dr.  Gayton,  in 
compiling  his  table,  threw  out  no  cases  of  superadded 
diseases,  so  that  Marson's  table,  as  we  have  recast  it,  is 
strictly  comparable  with  Gayton' s  : 


Cases. 

Deaths. 

Mortality 
per  cent. 

Unvaccinated   

2,169 

948 

43-7 

Stated  to  have  been  vaccinated,  but 

having  no  cicatrix  ... 

1,295 

352 

27-1 

Having  one  vaccine  cicatrix  ... 

1,988 

220 

11-07 

Having  two  vaccine  cicatrices  ... 

2,225 

178 

8-04 

Having  three  vaccine  cicatrices 

1,573 

82 

5-22 

;  Having  four  or  more  vaccine  cicatrices 

1,153 

37 

3-2 

In  comparing  these  two  tables,  we  at  once  notice  that  all 
the  death  percentages  of  Gayton's  table  are  in  excess  of 
Marson's.  For  instance,  Gayton's  death-rate  among  his 
unvaccinated  class  is  43*7,  while  Marson's  is  37*2.  As  far 
as  this  evidence  goes,  it  shows  that  small-pox  was  more 
fatal  among  the  unvaccinated  in  Gayton's  time  than  it 
was  in  Marson's  ;  that  being  so,  it  is  remarkable  that  if 
we  reduce  the  other  percentages  of  Gayton  by  the 
fraction  gf  we  arrive  at  results  which  are  almost  identical, 
and  on  such  an  inquiry  the  discrepancy  is  well  within  the 


54        THEORY  AND  PRACTICE  OF  VACCINATION 


limits  of  what  may  be  attributed  to  '  personal  equation,'  to 
borrow  a  phrase  used  in  astronomical  science. 

In  the  next  table  we  give  Gayton's  percentages  so  re- 
duced and  compared  with  Marson's : 


Marson's 
Mortality 
percentage. 

Gayton's  reduced 
,  37-2 
by4F r 

Unvaccinated 

Stated  to  have  been  vaccinated,  but 

having  no  cicatrix  ... 
Having  one  vaccine  cicatrix 

Having  two  vaccine  cicatrices  

Having  three  vaccine  cicatrices 
Having  four  or  more  vaccine  cicatrices 

37-2 

25*5 
92 
5-9 
36 
1-1 

23 
9-42 
6-9 
4-9 
19 

We  say  this  is  a  very  close  result  of  two  different 
observers,  and  shows  by  undesigned  coincidence  how 
accurate  both  must  have  been  in  the  collection  and  regis- 
tration of  such  a  mass  of  material. 

That  so  great  a  difference  should  be  observed  in  the  per- 
centage of  mortality  among  the  unvaccinated  between  the 
collection  of  Marson's  and  Gayton's  statistics,  seems  to  call 
for  some  comment.  We  do  not  think  that  there  is  any 
doubt  that  the  fatality  of  small-pox  has  been  increasing 
among  the  unprotected  class  since  the  commencement  of 
this  century,  that  is,  from  the  commencement  of  vaccina- 
tion. The  death-rate  among  those  having  the  natural 
disease  at  this  time  does  not  seem  to  have  been  greater,  at 
most,  than  22  per  cent. ;  for  out  of  1,200  who  took  small-pox 
in  Norwich  in  1807,  203  died,  i.e.,  16*9  per  cent.  Also  in 
the  village  of  Ware  in  1722,  612  persons  suffered  from  the 
small-pox,  of  which  number  72  died ;  this  gives  a  per- 
centage of  11  "7.* 

Dr.  J.  Kirkpatrick,!  in  1754,  quoting  Mr.  Wall,  of  the 
Inoculation  Hospital,  says  that,  out  of  1,415  small-pox 

*  See  Dr.  Monro's  '  Observations  on  the  Different  Kinds  of  Small- 
pox,' vol.  i.  of  the  Eoyal  Society's  MS.  Letters  and  Papers  concerning 
Inoculation,  p.  21. 

f  J.  Kirkpatrick,  '  The  Analysis  of  Inoculation,'  published  in  1754, 
p.  xxiv  in  the  preface. 


PRIMARY  AND  SECONDARY  VACCINATION  55 

patients  at  that  institution,  421  died,  or  27*75  per  cent.,, 
and  adds,  '  This  is,  indeed,  an  uncommon  proportion,'  and 
he  gives  some  reasons  to  account  for  it. 

Mr.  Cross  in  the  Norwich  epidemic  (before  mentioned) 
found  46  who  died  out  of  200  cases,  and  50  who  died  out 
of  357,  together  being  17*24  per  cent.  From  these  examples 
— and  they  are  not  selected  ones,  but  those  we  have  met 
with — in  all  they  amount  to  3,784  cases,  among  whom  there 
were  792,  or  2090.  This  we  will  take  as  the  death  per- 
centage at  the  commencement  of  this  century.  The  average 
time  at  which  Marson  collected  his  statistics  was  1846,  and 
he  gives  37*2  as  the  percentage  mortality  of  the  disease  at 
that  time. 

Dr.  Gayton,  in  1878,  being  the  mean  year  during  which 
he  was  collecting  his  cases,  found  the  percentage  mortality 
43*7.  Further,  Dr.  McCombie,  in  a  paper  entitled  '  Com- 
parison of  Small-pox  Statistic  Epidemics,  1871  and 
1876,'  compiled  from  reports  furnished  by  the  medical 
superintendents  of  the  various  small-pox  hospitals  of  the 
Metropolitan  Asylums  Board,*  gives  the  mortality  of 
the  1871  epidemic  as  44*6  per  cent.,  3,649  cases,  and 
1,628  deaths  ;  for  1876  epidemic  as  45*5  per  cent.,  1,693 
cases,  and  771  deaths.  Thus,  we  find  the  mortality 
at  the  commencement  of  the  century  22  per  cent. ;  in 
1846,  when  Marson  collected  his  statistics,  37*2  per  cent.  ; 
in  1878,  when  Gayton  collected  his  statistics,  43*7  ;  in 
the  epidemic  of  1871  the  mortality  was  44*6  ;  and  in  the 
epidemic  of  1876  the  mortality  was  45*5.  We  are  by  this 
led  to  believe  that  there  has  been  an  increasing  death-rate 
among  the  unprotected  portion  of  the  population.  If  this 
be  true,  of  what  value  is  the  argument  of  those  who  say 
the  diminished  fatality  of  small-pox  at  the  present  time  is 
due  not  to  vaccination,  but  to  the  exhaustion,  so  to  speak, 
of  the  disease,  and  that  our  present  immunity  from  the 
plague,  from  typhus,  and  from  leprosy,  are  analogous 

*  Transactions  of  the  Epidemiological  Society,  vol.  iv.,  1875-81 
p.  188. 


56        THEORY  AND  PRACTICE  OF  VACCINATION 


instances  ?  We  have  shown  a  reason  for  believing  small- 
pox, instead  of  decreasing  in  fatality,  has  really  doubled  in 
virulence  among  a  certain  class,  viz.,  the  un vaccinated. 

The  reason  for  this  increase  of  small-pox  fatality  among 
the  unvaccinated  population  is,  we  believe,  the  following  : 
When  a  disease  has  become  endemic  in  a  country  for  some 
centuries,  and  spreads  among  the  population  unchecked, 
we  generally  find  the  tendency  is  for  the  mortality  from 
such  a  disease  to  decrease.  Especially  would  this  be  the 
case  with  a  disease  like  small-pox,  which  we  have  already 
shown  to  be  a  disease  of  childhood  in  unvaccinated  com- 
munities. Almost  everybody  has  the  disease  at  some 
period  of  life,  in  the  great  bulk  of  people  before  they  are 
twelve  years  old.  Hence  most  individuals  would  have  had 
their  attack  of  small-pox  before  marriage,  and  chiefly  those 
who  had  successfully  combated  the  disease  would  be  propa- 
gators of  their  race.  We  will  take  for  granted  the  fact 
that  physical  properties  are  largely  inherited,  and  there- 
fore the  children  of  those  parents  who  had  successfully 
combated  the  disease  would  be  more  likely  to  combat 
successfully  with  the  same  disease,  i.e.,  they  would  inherit 
a  power  more  or  less  of  resisting  death  from  small-pox, 
and  in  this  sense  might  be  called  stronger  than  those  who 
would  die.  The  population  would,  after  some  years,  become 
gradually  strengthened  against  death  from  small-pox,  and 
the  mortality  of  the  disease  would  decrease. 

Any  method  which  would  allow  all  to  live  and  propagate 
their  kind,  such  as  vaccination,  would  remove  this  means 
of  strengthening  the  population  against  small-pox,  and 
hence  those  of  the  population  who  did  not  avail  them- 
selves of  the  method  of  safety  would,  after  some  years, 
feel  the  full  brunt  of  the  disease,  and  thus  the  fatality 
would  gradually  increase  among  them  to  such  a  degree 
as  we  know  the  mortality  to  be  among  a  community 
which  has  never  as  yet  had  the  disease,  or  not  had  it 
for  some  long  time  among  them.  We  may  instance  how 
very  fatal  syphilis  was  when  it  first  appeared  in  Europe, 


PRIMARY  AND  SECONDARY  VACCINATION 


57 


and  how  fatal  measles  was  among  the  Fijians  in  our  own 
time  (1875).  It  is  true  Dr.  Corney  attributes  this  mortality 
to  the  mistreatment  of  the  disease  by  the  natives.  On 
page  84  of  the  Transactions  of  the  Epidemiological  Society, 
vol.  iii.,  1883-84,  indeed,  he  mentions  the  reason  we  have 
given  for  the  high  mortality,  but  only  to  reject  it.  We 
may,  therefore,  be  allowed  to  form  our  own  opinion  upon 
the  matter. 

Another  factor  which  we  know  influences  the  return 
journey  along  our  imaginary  line  is  the  character  of  the 
lymph  used.  As  an  illustration  we  will  relate  the  follow- 
ing details  :  On  December  15,  1875,  we  vaccinated  a  child, 
E.  C,  six  months  old,  in  four  places.  On  the  22nd  the 
child  returned  with  two  very  small  vesicles.  The  child 
had  four  more  places  inoculated  on  the  22nd,  and  when  it 
returned  on  the  29th  these  were  found  to  have  all  taken. 
Lymph  was  then  taken  from  it  and  used  for  the  vaccination 
of  eight  children  in  four  places  each.  Of  these  the  vaccina- 
tion failed  in  four  cases,  one  apparently  took  in  three  places, 
and  two  others  in  two  places,  producing  small  sores, 
with  a  light  yellow  scab.  The  one  that  was  vaccinated  in 
three  places  the  mother  refused  to  have  done  again,  but 
the  other  two  were  re-vaccinated,  one  on  January  12,  1876, 
and  the  other  on  March  8,  and  both  took  well  in  four 
places.  This  could  not  have  been  the  case  if  the  lymph 
had  been  taken  at  the  proper  time.  From  this  case  we 
may  learn  that  lymph  taken  fourteen  days  after  the  first 
inoculation  which  is  successful,  though  it  be  taken  on  the 
eighth  day  from  the  inoculation  of  the  yielding  vesicle 
— that  such  lymph,  though  capable  of  producing  a  local 
lesion  on  another  individual,  is,  nevertheless,  incapable  of 
rendering  the  system  immune  from  further  vaccination. 

Some  apology  to  our  readers  seems  called  for  for  describing 
this  last  experience  of  ours.  It  must  be  remembered  that 
the  circumstances  to  which  it  relates  occurred  nearly 
seventeen  years  ago,  before  we  had  our  present  experience, 
and  want  at  the  time  of  knowledge  must  be  our  excuse. 


58        THEORY  AND  PRACTICE  OF  VACCINATION 


In  Nature  of  March  22,  1888,  there  is  a  short  review  of 
Dr.  C.  Creighton's  book,  '  Cow-pox  and  Vaccinal  Syphilis,' 
and  there  we  offer  what  we  consider  a  very  striking  analogy 
which  exists  between  vaccination  and  syphilis.  We  assume, 
however,  a  controversial  matter,  that  of  the  original  identity 
of  the  virus  of  the  two  kinds  of  venereal  sores.  For  we 
believe  that  the  virus  producing  the  hard  infecting  sore  is 
that  inoculated  at  the  time  of  its  potency,  whereas  the 
virus  which  produces  the  local  lesion  only,  or  soft  sore,  is 
that  inoculated  at  a  time  when  the  virus  is  old.  In  think- 
ing rationally  of  this  analogy,  we  might  bear  in  mind  the 
respective  incubatory  periods  of  the  two  diseases,  syphilis 
and  vaccinia,  the  latter  being  so  much  longer  than  the  former, 
and  consequently  the  much  greater  opportunities  in  the 
latter  of  getting  a  degenerate  virus. 

There  is  also  another  cause  that  influences  the  return 
march,  which  we  can  describe  less  definitely  than  the  other 
two  causes  ;  but  nevertheless  it  is  quite  as  efficient,  or  even 
more  so,  to  hurry  or  delay  the  return  march.  We  will 
name  this  '  individual  peculiarity.'  As  an  example  of  what 
we  mean,  we  will  instance  the  liability  of  certain  individuals 
to  take  small-pox  twice  in  their  lives.  This,  however,  is  very 
well  known  to  be  the  exception  of  the  ordinary  experience, 
and  we  can  at  present  only  attribute  this  liability  to  some 
individual  peculiarity,  but  of  this  we  will  speak  more  fully 
when  on  the  subject  of  re-vaccination.  There  may  be  other 
causes  which  influence  the  return  march  which  we  know 
little  or  nothing  about,  but  the  three  we  have  given  will 
suffice  for  our  purpose  of  illustration. 

We  will  now  suppose  a  person  once  vaccinated  and  to 
have  arrived  at  the  desirable  point  9  of  our  imaginary  line, 
and  let  us  assume  that  every  individual  once  vaccinated  has 
a  tendency  to  return  to  his  original  condition,  represented  by 
0  on  this  line.  We  will  further  suppose  that  his  return  march 
is  gradual,  and  that  he  has  returned  as  far  as  the  position 
marked  4  on  the  line.  If  such  an  individual  were  now 
re-vaccinated  he  would  take  up  the  disease  at  4,  and  then 


PRIMARY  AND  SECONDARY  VACCINATION  59 


again  complete  his  journey  at  9.  The  re- vaccination  would 
only  run  a  five  days'  course.  On  this  theory,  the  more 
rapid  course  a  re- vaccination  ran  in  an  individual,  the  longer 
time  that  individual  would  have  before  he  could  contract 
small-pox.  There  are  reasons  for  thinking  that  an  individual 
would  not  be  liable  to  contract  natural  small-pox  until  he 
had  returned  as  far  as  the  position  marked  4.  That  is  to 
say,  if  his  re-vaccination  took  five  days  before  the  vesicles 
were  at  their  height,  then  we  may  regard  such  an  individual 
to  have  just  arrived  at  the  point  in  his  return  march  at 
which  he  would  take  small-pox  if  exposed  to  it ;  that  if  he 
was  between  three  and  four  he  would  have  but  a  modified 
attack,  and  if  beyond  three  on  his  return  journey,  then  he 
would  have  small-pox  as  badly  as  if  he  had  never  been 
vaccinated. 

What  reasons  have  we  for  asserting  this  dogma  ?  Marson, 
in  his  article  on  small-pox,  published  in  vol.  i.,  p.  477,  of 
Keynolds'  '  System  of  Medicine/  lays  down  the  following 
law  after  the  observation  of  many  cases.  He  says  the 
incubatory  period  of  small-pox  is  twelve  days,  and  that  if 
a  person  be  vaccinated  during  the  first  three  days  of  the 
incubatory  period  of  small-pox,  such  a  person  would  escape 
the  later  disease  entirely ;  but  if  a  person's  vaccination  was 
delayed  till  between  the  third  and  fourth  days  of  the  incu- 
batory period  of  small-pox,  then  he  would  have  a  modified 
attack  of  the  disease,  and  if  the  vaccination  was  still  further 
delayed  beyond  the  fourth  day  of  the  incubatory  period, 
then  such  an  individual  would  have  small-pox  and  vaccinia 
together,  the  one  disease  being  uninfluenced  by  the  other. 
We  have  seen  several  cases  which  have  entirely  corroborated 
Marson's  law,  so  that  we  have  every  reason  to  believe  it 
true.  We  will  relate  three  cases,  for  they  will  illustrate 
not  only  our  direct  object,  but  also  indirectly  one  of  two 
others  we  wish  to  insist  on. 

Case  I. — The  following  case  is  partially  given  on  page  10, 
but  it  is  now  more  fully  related : 

A  woman's  husband  was  taken  ill  with  small-pox  on 


6o        THEORY  AND  PRACTICE  OF  VACCINATION 


Wednesday,  December  20,  1871.  She  had  three  un vac- 
cinated children,  two  girls  and  a  boy.  These  she  took  to 
Surrey  Chapel  on  the  following  Tuesday,  December  26, 
to  be  vaccinated.  They  were  apparently  vaccinated  by 
Mr.  Marson  in  six  places,  three  being  placed  on  each  arm, 
in  a  position  with  regard  to  each  other  which  was  habitual 
with  Mr.  Marson.  The  names  and  ages  of  the  children 
were :  Herbert,  aged  six ;  Clara,  aged  four  ;  and  Laura, 
aged  three  months — the  last  having  been  born  on  Sep- 
tember 24,  1871.  The  two  girls  became  ill  with  small-pox 
on  Sunday,  December  31,  i.e.,  on  the  twelfth  day  after  their 
father,  and  they  were  vaccinated  on  the  seventh  day  of  the 
incubatory  period  of  small-pox.  Clara  died  on  January  8, 
1872,  of  the  disease,  although  her  vaccination  had  taken  as 
well  as  Laura's.  Herbert  escaped  altogether.  Laura  we 
saw  on  January  16,  1895,  at  St.  Thomas's  Hospital.  She 
was  then  severely  scarred  with  small-pox,  and  had  lost  an 
eye  from  the  disease.  She,  however,  bore  six  good  foveated 
scars  of  vaccination,  such  as  we  have  seldom  seen  produced 
on  a  person  who  has  previously  suffered  from  small-pox. 
She  affirmed  that  she  was  vaccinated  before  she  had  small- 
pox, but  knew  nothing  further  of  her  vaccination.  She, 
however,  gave  me  her  mother's  address,  and,  upon  calling, 
her  mother  related  the  above  particulars,  except  for  the 
exact  dates.  These,  however,  we  are  able  to  supply  from 
the  register  of  the  time,  which  was  found  to  tally,  as  far  as 
it  went,  precisely  with  the  mother's  story. 

Case  II. — A  policeman  brought  three  of  his  children 
to  be  vaccinated  at  Victoria  Hall.  They  were  aged  re- 
spectively 11,  9,  and  7  years.  The  eldest  was  a  boy,  the 
two  others  girls.  These  three  children  were  vaccinated  on 
May  26,  1881.  Two  of  the  children  had  been  sleeping  in 
the  same  room  with  their  elder  brother,  and  his  eruption 
of  small-pox  first  appeared  on  May  18. 

Having  paid  some  attention  to  the  infective  power  of 
small-pox  during  its  incubatory  stage,  we  have  come  to  the 
conclusion  that  small-pox  is  not  infective  to  other  persons 


PRIMARY  AND  SECONDARY  VACCINATION  61 


until  this  stage  is  over.  The  chances  of  two  unvaccinated 
children  sleeping  in  the  same  room  as  one  with  small-pox 
are  greatly  that  they  contract  small-pox  at  the  earliest  date 
possible,  and  that  will  be,  according  to  our  experience,  twelve 
days  after  the  appearance  of  the  disease  in  the  first  attacked. 
We  should  therefore  look  on  May  30  as  the  day  on  which  the 
eruption  should  appear  in  the  two  unvaccinated  children, 
and  this  day  really  was  the  first  day  on  which  the  two 
children  manifested  the  disease.  In  the  other,  where  the 
probability  of  infection  was  not  so  great — i.e.,  in  the  child 
who  was  not  sleeping  in  the  same  room,  but  who  had  access 
to  her  brother's — the  child  fell  with  the  small-pox  two 
days  later.  Thus  we  see  in  this  man's  family,  consisting 
of  himself  and  five  children,  only  the  man  himself  and  his 
youngest  child — both  of  whom  had  been  vaccinated  some 
time  previous  to  exposure — escaped,  while  all  the  rest  had 
small-pox.  Three  of  these  latter  were  vaccinated  on  the 
ninth  day  of  the  possible  exposure,  and  these  all  had  small- 
pox as  badly  as  they  could  have  it.  The  other,  who  was 
the  eldest  lad,  and  who  had  never  been  attempted  to  be 
vaccinated,  also  had  the  disease  severely.  We  may  add 
that  we  visited  the  cases,  which  were  admitted  to  the  Stock- 
well  Small-pox  Hospital,  and  they  all  presented  the  appear- 
ance of  the  unmodified  form  of  the  disease.  The  vaccination 
had  taken  in  all  three  in  every  place,  and  the  small-pox 
eruption  was  even  more  abundantly  distributed  within  the 
area  of  that  occupied  by  the  vaccine  vesicles,  and  for  a  short 
distance  around.  These  cases,  therefore,  we  may  reason- 
ably suppose  were  vaccinated  on  the  ninth  day  of  the 
incubatory  period  of  small-pox,  which  was  not  modified 
thereby.  We  saw  both  the  individuals  who  were  vaccinated 
on  May  26,  1881,  one  on  June  15,  1895  ;  the  other  on 
July  10,  1895.  Both  of  them  were  pitted,  and  both  had 
five  indistinct  scars  of  vaccination.  Another  case  which  we 
think  worth  recording,  because  the  dates  we  can  also 
accurately  give ;  but  the  subject  of  this  record  had  been 
previously  vaccinated  in  infancy,  and  therefore  the  deduc- 


62        THEORY  AND  PRACTICE  OF  VACCINATION 

tions  to  be  drawn  are  not  of  so  much  value  as  in  the  former 
example. 

Caselll. — A  gentleman,  aged  twenty-three  years — a  house- 
surgeon  at  St.  Thomas's  Hospital — in  the  beginning  of  the 
year  1871,  which  will  be  remembered  as  the  greatest 
epidemic  year  of  small-pox  since  the  introduction  of  vaccina- 
tion, saw  and  attended  to  a  man  who  had  been  admitted 
with  a  fractured  leg,  and  afterwards  developed  small-pox. 
The  date  on  which  he  contracted  small-pox  was  probably 
January  30,  1871.  On  February  1  he  was  vaccinated  on 
the  right  arm,  and  on  Wednesday,  the  8th,  he  was  taken  ill 
with  what  proved  to  be  small-pox,  and  admitted  to  the 
small-pox  ward  on  the  9th.  He  had  an  abundant  eruption, 
but  this  was  not  present  on  the  right  arm,  or  for  an  area 
round  the  vaccine  vesicles.  Here  vaccination  was  presum- 
ably done  between  the  third  and  fourth  days  of  the  incubatory 
period.  The  attack  was  a  mild  one,  and  this  gentleman's 
face  is  not  pitted  or  disfigured  in  any  way.  It  is  true  that 
his  previous  vaccination  in  infancy  must  have  had  much  to 
do  with  the  modification  of  the  disease,  but  the  fact  of  there 
being  no  small-pox  eruption  on  the  right  arm,  and  for  a 
certain  area  round  the  vaccine  vesicles,  showed  that  the 
then  present  vaccination  had  some  modifying  effect, 
especially  when  we  remember  that  in  the  first  case  reported 
the  small-pox  eruption  was  more  abundant  between  the 
vaccine  vesicles,  and  for  some  short  distance  in  the  area 
around  them.  From  the  observation  of  such  cases  as  the 
three  above  related,  Marson  deduced  his  theory,  and  as 
the  three  cases  which  we  have  met  with  are  entirely  in 
accord  with  Marson's  experience,  we  accept  it. 


LECTURE  IV. 


THE   ERUPTIONS  THAT  OCCASIONALLY  FOLLOW  VACCINATION. 


When  we  first  began  vaccinating  we  made  it  a  rule  to  inquire 
into  the  history  of  all  children  who  had  eruptions  following 
vaccination,  especially  those  on  whom  the  rash  presented 
any  appearance  of  syphilis.  We  know  very  well  what  the 
ordinary  course  of  acquired  syphilis  is.  Briefly  to  recall 
the  chief  points  important  for  our  present  purpose,  they 
are  :  first,  a  period  of  incubation  of  about  three  to  five 
weeks,  and  this  rule  holds  on  whatever  part  of  the  skin  the 
individual  may  inoculate  him  or  herself ;  second,  there  is 
another  interval  of  time  between  the  development  of  the 
chancre  and  the  appearance  of  the  rash.  This  second  interval 
is  usually  about  two  to  four  weeks  more  ;  so  that  it  would 
be  five  to  nine  weeks  from  the  inoculation  of  syphilis  until 
we  saw  the  secondary  rash  upon  the  body.  The  ordinary 
course  of  hereditary  syphilis  is  for  the  appearance  of  the 
rash  to  follow  after  the  same  interval  that  occurs  in  the 
acquired  disease  between  the  development  of  the  chancre 
and  the  appearance  of  the  secondary  rash,  the  interval 
between  the  inoculation  and  the  development  of  the  chancre 
being  annihilated.  Now,  eruptions  which  follow  vaccination, 
even  if  of  a  syphilitic  nature,  nearly  always  appear  about 
the  tenth  day  after  vaccination,  and  it  follows,  that  if  this 
appearance  of  a  syphilitic  rash  on  the  tenth  day  is  due  to 
the  inoculation  of  syphilis  at  the  time  of  vaccination,  the 
disease  in  such  cases  persistently  follows  a  very  unusual 


64        THEORY  AND  PRACTICE  OF  VACCINATION 


course.  This  unusual  course  is  not  to  be  noticed  in  the 
twenty-six  cases  or  so  which  Mr.  Hutchinson*  has  published 
of  syphilitic  inoculation  after  vaccination,  and  in  one  case 
which  we  saw  the  disease  followed  its  usual  course  unmodi- 
fied by  vaccination.  For  instance,  it  took  twenty-one  days 
from  the  vaccination  to  the  first  appearance  of  the  chancre, 
and  thirty-six  days  from  the  first  appearance  of  the  chancre 
to  the  appearance  of  the  secondary  rash — fifty-seven  days  in 
all,  or  one  day  more  than  eight  weeks.  Hence  we  may  fairly 
assume  that  when  syphilis  is  inoculated  at  the  time  of 
vaccination  it  will  follow  its  usual  course.  The  explanation 
why  the  eruption  appears  so  frequently  on  the  tenth  day  of 
vaccination  is,  we  think,  because  the  child  so  affected  is  suffer- 
ing already  from  hereditary  syphilis,  and  the  skin  irritation 
occasioned  by  the  vaccination  simply  determines  the  time 
of  the  appearance  of  the  rash.  Vaccination,  there  is  no 
doubt,  is  a  cutaneous  irritant,  much  less  so,  however,  than 
small-pox.  With  the  former  it  is  only  the  weak  skins,  or 
those  suffering  from  some  idiosyncrasy,  that  suffer.  In  the 
latter  the  irritation  is  so  strong  that  all  skins  break  down, 
and  that  in  a  definite  manner,  and  the  rash  is  therefore 
characteristic  of  the  disease. 

The  rashes  which  follow  vaccination,  however,  are  not 
definite— in  fact,  are  as  numerous  in  character  as  there  are 
rashes  to  which  children  are  liable  ;  they  are  determined 
more  by  the  nature  of  the  child's  organism  in  whom  they 
occur  than  by  the  vaccinia.  It  is  thus  we  explain  the 
very  various  forms  of  eruption  which  are  met  with  after 
vaccination  :  it  may  be  a  general  erythema,  or  an  eczema, 
or  an  urticuria,  or  a  lichen,  or  may  partake  of  the  appearance 
of  any  other  rash  to  which  children  are  liable.  Measles, 
scarlet  fever,  and  small-pox  have  each  of  them  their  own 
special  character  of  rash,  so  that,  from  seeing  them,  it  is 
possible  to  say  to  which  of  these  diseases  they  are  to  be 
referred.  With  vaccinia  this  is  impossible,  the  appearance 
of  the  rash,  if  it  exist  at  all,  being  so  indefinite.  It  is  well 
*  '  Illustrations  of  Clinical  Surgery,'  1875. 


I 


PLATE  V 


ERUPTIONS  THAT  FOLLOW  VACCINATION 


65 


known  that  certain  local  irritations  are  sufficient  to  cause 
lesions  in  weak  skins.    Thus,  the  wet  napkin  will  cause 
intertrigo ;  a  common  head  cold  will  cause  sores  about  the 
orifice  of  the  nose ;  the  saliva  will  cause  the  angles  of  the 
mouth  to  be  cracked,  sore,  and  tender  ;  and  the  perspiration 
from  the  head  will  cause  impetiginous  sores  behind  the  ear, 
etc.  On  skins  on  which  these  local  conditions  are  sufficiently 
potential  to  cause  mischief,  vaccination  will  also  be  potential 
to  do  the  same,  and  the  vaccine  vesicle  will  be  ill-developed 
or  abnormal  in  appearance,  and  cannot  be  expected  to  confer 
the  most  lasting  immunity  from  small-pox  that  vaccination 
is  capable  of  affording.    For  a  common  appearance  of  the 
vaccine  vesicle  under  the  above  abnormal  conditions  see 
Plate  IX.,  Lecture  V.,  p.  70.     Fig.  1,  Plate  V.,  was  taken 
from  a  child  whose  father  contracted  syphilis  shortly  before 
his  marriage.    It  was  the  second  child  of  the  marriage  ;  the 
first  died  within  a  very  short  period  of  birth.    This  child, 
being  apparently  healthy,  was  vaccinated  at  St.  Thomas's 
Hospital  in  1878.    It  was  duly  inspected,  and  was  brought 
again  with  the  eruption  represented,  which  first  appeared 
on  the  tenth  day  after  vaccination.    This  is  a  very  good 
example  of  the  cases  of  alleged  syphilis  after  vaccination. 
It  is  so  tempting  for  parents  to  lay  the  results  of  their  own 
iniquities  upon  vaccination,  especially  when  they  are  en- 
couraged so  to  do  by  shameless  agitators.    To  enable  us  to 
view  the  truth  of  these  allegations  against  vaccination,  we 
will  suppose  a  man  to  have  had  syphilis  and  to  play  a 
game  of  football :  he  receives  a  kick  on  the  shin,  and  in 
due  course  a  syphilitic  node  may  develop  from  the  bruise. 
The  man  would  be  as  entitled  to  say  he  acquired  his  syphilis 
from  playing  football  as  a  parent  of  a  child  who  has  had 
syphilis  would  be  to  say  that  the  child  acquired  its  syphilis 
from  vaccination. 

There  is  one  more  most  striking  fact  which  receives  an 
easy  explanation  from  the  above  view,  and  would  be  other- 
wise quite  incomprehensible  without  it.  We  allude  to 
syphilitic  eruptions  following  the  use  of  calf  lymph,  and 

5 


66        THEORY  AND  PRACTICE  OF  VACCINATION 


that  about  in  the  same  proportion  as  after  the  use  of 
human  lymph.  It  may  be  accepted  without  doubt  that 
calf  lymph  which  has  never  passed  through  the  human 
being  since  its  origin  is  perfectly  free  from  the  syphilitic 
taint,  and  yet  syphilitic  eruptions  follow  its  use.  This  fact 
alone  should,  in  this  particular  of  syphilitic  infection, 
restore  our  confidence  in  the  use  of  human  lymph. 

Another  eruption  to  which  children  are  subject  after 
vaccination  is  urticaria.  It  is  well  known  that  adults  who 
are  liable  to  urticaria  may  have  it  readily  excited  by  slight 
causes.  Thus,  a  scratch  is  often  sufficient,  or  a  meal  of 
shell-fish,  especially  crabs  or  mussels.  Oatmeal  will  pro- 
voke it  in  others ;  strawberries  in  others,  etc.  Plate  V., 
Fig.  2,  represents  a  severe  form  of  the  eruption  as  it 
occurred  in  a  child,  A.  K.  T.,  in  1879.  Plate  VI.,  Fig.  1, 
also  represents  the  right  flank  of  the  same  child,  and 
Plate  VI.,  Fig.  2,  represents  some  of  the  spots  about  the 
natural  size,  with  the  details  filled  in.  The  child  was 
vaccinated  on  November  4,  at  Surrey  Chapel,  from  human 
lymph.  The  rash  first  appeared  on  November  13  ;  the 
drawing  was  taken  on  November  19.  On  the  sides  of  the 
cheeks,  on  the  dorsum  of  the  feet  and  the  backs  of  the 
hands,  the  eruption  became  vesicular  or  even  bulbous ;  but 
not  so  on  other  parts  of  the  body.  This  severe  form  of  the 
rash  follows  vaccination  in  about  1  in  10,000  cases.  It  is  as 
common  after  calf  lymph  as  after  human  lymph,  and  the 
inoculation  of  another  child  with  the  serum  from  the 
vesicles  produces  no  result,  having  first  ascertained  its 
harmlessness  by  self -inoculation.  The  eruption  again 
appeared  two  or  three  months  later  during  dentition. 
Plate  VII.  represents  an  urticaria,  the  drawing  being  taken 
at  a  late  stage  of  the  eruption. 

Another  eruption  which  happens  after  vaccination  is 
eczema,  chiefly  occurring  about  the  head  and  face,  or  as 
intertrigo  about  the  buttocks,  axilla,  or  in  the  folds  of  the 
neck.  Impetigo  behind  the  ears  is  also  met  with,  and 
tinea  tarsi ;   but  these  evils  are  often  excited  by  local 


"West,  Ifevvaoaa-ri  chromo 


PLAT  E  VII 


West. Newman  cTafomo. 


P  L  ATE  VIII. 


West, Newman  cKromo 


ERUPTIONS  THAT  FOLLOW  VACCINATION 


67 


irritations,  as  we  have  already  said,  before  vaccination, 
and  only  when  they  occur  after  vaccination  can  vaccination 
be  truthfully  accused  of  being  an  exciting  cause. 

Lichen  in  its  various  forms  may  also  follow  vaccination, 
but  lichen  also  occurs  during  dentition  in  some  children. 
See  Plate  VIII.,  which  illustrates  this  in  a  severe  form ; 
this  rash  came  out  on  the  tenth  day  after  vaccination  from 
calf  lymph.*  When  lichen  occurs  during  dentition,  this, 
we  think,  must  be  caused  by  some  abnormal  process  of 
digestion ;  the  irritation  of  the  mouth  reaches  the  stomach, 
thus  giving  rise  to  the  abnormal  process.  The  abnormal 
products  are  absorbed,  and  these,  circulating  in  the  blood, 
irritate  the  skin  and  occasion  the  eruption  which  at  such 
time  often  appears.  Mothers,  as  a  rule,  are  quite  aware 
that  their  infants  may  suffer  from  eruptions  of  various  kinds 
during  dentition,  and  they  are  content  when  they  say  that 
the  child  has  a  gum  rash.  They  then  rightly  never  think 
of  attributing  it  to  the  impurity  of  the  tooth  that  the  child 
has  just  cut,  but  if  the  eruption  happens  to  follow  vaccina- 
tion the  hated  rite  gets  the  blame. 

We  have  once  seen  purpura  follow  vaccination  in  the 
same  way  as  purpura  may  be  an  early  symptom  of  small- 
pox. Haemorrhage  into  the  vesicles  we  have  also  seen 
in  one  child  who  was  suffering  from  whooping-cough. 
Haemorrhage  in  this  case  was  no  doubt  due  to  the  conges- 
tion of  the  skin  caused  during  the  paroxysms  of  the  cough. 

Mr.  Hutchinson,  on  December  9,  1879  (British  Medical 
Journal,  p.  960,  December  13,  1879),  exhibited  the  body  of 
a  child  (at  the  Medico- Chirurgical  Society)  which  had  been 
vaccinated  on  November  11.  An  eruption  had  come  out 
by  the  eighth  day,  which  the  medical  man  under  whose 
care  it  was  believed  to  be  variola.  Three  days  later  the 
vesicles  of  the  eruption  were  surrounded  by  large  red 
areolae,  which  became  circular  gangrenous  patches.  The 
skin  where  the  eruption  had  been  was,  at  the  time  the 

*  The  artist  has  not  been  happy  in  the  representation  of  the  body 
form,  but  the  eruption  is  faithfully  represented. 

5—2 


68        THEORY  AND  PRACTICE  OF  VACCINATION 


body  was  exhibited,  as  if  it  had  had  a  hole  punched  out, 
so  abrupt  were  the  margins  of  the  wounds.  Another  case 
of  this  complication  after  vaccination  is  published  in  the 
Dublin  Journal  of  Medical  Science  for  June,  1880,  by 
Mr.  William  Stokes. 

The  child  in  question  was  vaccinated  on  February  7, 
1880.  On  the  morning  of  the  9th  a  number  of  purple  and 
black  spots  appeared  first  on  the  buttocks,  next  on  the 
face,  and  subsequently  all  over  the  body.  The  sloughs 
appeared,  as  in  Mr.  Hutchinson's  case,  over  the  sites  of 
the  eruption.  There  were  three  well  -  marked  vaccine 
vesicles  on  the  arm,  which  appeared  healthy. 

In  Guy's  Hospital  museum  there  are  two  wax  models  of 
what  is  called  varicella  gangrenosa.  These  exactly  resemble 
the  gangrenous  patches  in  Mr.  Hutchinson's  case,  and  we 
think  the  same  conditions  of  system  were  present  in  all 
those  children  who  so  suffered — two  after  vaccination  and 
two  after  chicken-pox — and  we  are  inclined  to  believe  that 
disseminated  tubercle  was  the  real  cause  of  them. 

Auto-vaccination  is  occasionally  seen.  We  have  seen  it 
in  children  who  had  intertrigo  in  the  groin,  and  who,  after 
scratching  their  vaccinated  arms,  had  transferred  their 
hand  to  their  groins,  thus  producing  a  crop  of  vesicles  on 
this  part.  We  have  also  seen  vaccine  vesicles  on  the  face 
from  the  same  cause,  and  we  have  twice  seen  a  general 
eruption  of  vaccine  vesicles  on  the  body  in  children  who 
had  been  vaccinated.  In  both  these  cases  the  children  were 
in  public  institutions,  and  had  been  thoroughly  washed 
every  morning  by  a  nurse  of  the  institution.  As  tow  is 
very  properly  used  in  general  instead  of  a  sponge,  and  the 
vaccinated  arm  had  taken  part  in  the  ablution,  the  tow, 
having  been  wiped  over  the  rest  of  the  skin,  had  caused  a 
general  inoculation  of  the  surface.  This  seems  to  be  more 
frequent  in  France  than  in  England,  and  the  French  have 
given  it  the  name  of  vaccina  generalisee ;  but  that  it  is  due 
to  wholesale  auto-vaccination  we  have  little  doubt. 


LECTUEE  V. 


THE  PRACTICAL  DETAILS  OF  VACCINATION. 

We  shall  first  speak  of  the  lymph  which  it  is  best  to  use, 
and  how  it  should  be  used. 

It  is  always  best  to  use  perfectly  fresh  lymph,  and  to 
vaccinate  directly  from  arm  to  arm  or  from  calf  to  arm.* 
The  lymph  used  from  child  to  child  should  be  taken  not 
later  than  the  eighth  day,  i.e.,  on  the  day  week.  The  child 
which  is  to  be  the  vaccinifer  is  vaccinated,  say,  on  Tuesday, 
and  the  following  Tuesday  the  lymph  should  be  taken. 
The  lymph  should  not  be  taken  later  than  on  this  day,  for 
if  it  be,  it  has  a  great  tendency  to  produce  unduly  inflamed 
arms  on  the  children  vaccinated,  or  to  produce  abortive 
vesicles,  called  by  the  first  vaccinators  spurious  vesicles. 
These  vesicles  may  not  be  protective  against  further 
vaccination,  and  certainly  do  not  give  that  lasting  pro- 
tection against  small-pox  that  properly  performed  vaccina- 
tion is  capable  of  giving.  The  lymph  may  be  taken  earlier 
without  the  chance  of  these  untoward  results,  but  it  is 
difficult  to  obtain  any  quantity  on  the  earlier  days. 
Further,  the  lymph  taken  after  the  day  week  is  seldom 
effective  after  a  week's  storing. 

Lymph  from  a  re-vaccination  should  in  no  case  be  used  ; 
nor  should  lymph  from  a  much -inflamed  arm,  or  lymph 
that  is  thin  or  serous.    Thick  lymph,  which  at  first  oozes 

*  In  saying  this,  gentlemen,  I  should  tell  you,  however,  that, 
although  such  has  been  the  policy  of  the  Local  Government  Board  up 
to  the  present  time,  there  is  the  probability  that  this  policy  before  long 
will  be  altered,  when  different  instructions  will  have  to  be  given. 


7o        THEORY  AND  PRACTICE  OF  VACCINATION 


from  the  vesicle  when  it  is  pricked,  should  be  used.  No 
child  that  is  unhealthy  or  has  any  skin  eruption  should 
be  used  as  a  vaccinifer,  and  in  all  cases  care  should  be 
taken  to  examine  the  buttocks  of  any  child  from  whose 
arm  the  lymph  is  taken  to  vaccinate  another.    This  last 
precaution  is  very  necessary,  for  we  are  able  to  eliminate 
all  cases  of  dangerous  children.    Syphilitic  children  during 
the  latent  or  incubatory  period  of  the  disease  are  not  in- 
fective, but  become  so  immediately  the  symptoms  declare 
themselves.    It  has  been  thought  that  if  the  lymph  was 
used  unmixed  with  blood  then  there  was  no  chance  of  con- 
veying syphilis ;  but  this  is  an  error.     The  proper  pre- 
caution to  take  is  to  note  if  there  be  any  symptoms  of  the 
disease  present  in  the  vaccinifer,  and  to  reject  all  suspicious 
children.    The  lymph  from  an  apparently  healthy  child  is 
perfectly  safe,  although  it  may  be  incubating  the  disease. 
Eczema  in  children  is  a  skin  disease  which  frequently 
causes  the  vesicles  to  be  ill-formed  and  sloughy  -  looking, 
of  which  Plate  IX.  represents  a  case.     Of  course  lyrnph 
should  never  be  taken  from  an  abnormal  vesicle  to  vaccinate 
others.     Lymph  which  is  carelessly  selected  has  a  great 
tendency  to  become  weak,  i.e.,  it  produces  persistently  what 
are  called  advanced  arms,  that  is,  an  arm  where  the  areola 
is  formed  on  the  seventh  day  instead  of  the  eighth,  and  is 
consequently  very  well  marked  on  the  eighth  day,  when  it 
should  only  be  forming.    Some  practitioners  consider  the 
eighth  too  early  for  the  areola  to  be  present,  but  we  are 
sure  this  is  a  mistake.   We  always  like  to  see  a  little  areola 
on  the  eighth  day.    If  there  is  none,  the  child  is  often  out 
of  health,  or  has  possibly  been  taking  mercury  in  some 
form,  usually  as  gray  powder.    We  have  noticed  this  to  be 
the  case  over  and  over  again,  viz.,  that  mercury  has  the 
power  of  delaying  the  appearance  of  the  areola.    We  have 
also  given  mercury  in  healthy  infants  for  a  week  before 
vaccination,  and  continued  the  drug  during  vaccination,  with 
the  same  result.  Plate  X.  shows  a  typically  good  arm,  from 
which  lymph  might  be  taken. 


West, Newman  chfomo 


PLATE  X 


West, Newman  chrome 


PLATE  XI 


West,Newman  cTnr-om.0 


THE  PRACTICAL  DETAILS  OF  VACCINATION  71 


The  vesicles  should  be  pricked  towards  the  margins  with 
an  ordinary  sharp  bleeding  lancet,  the  flat  of  the  instrument 
being  held  parallel  to  the  surface  of  the  skin  (Plate  XL). 
In  this  way  blood  is  usually  avoided.  It  would  be  otherwise 
if  the  lancet  were  held  perpendicularly.  The  vesicle  should 
be  pricked  all  round  the  margin,  for,  as  we  have  before 
stated,  the  lymph  is  contained  in  a  sort  of  honeycombed 
structure,  and  therefore  requires  a  good  many  punctures 
for  its  liberation  (Plate  II.,  p.  43). 

If  the  vesicles  be  shallow,  they  are  very  difficult  to  prick 
without  drawing  blood,  and  if  this  should  happen,  care 
must  be  taken  not  to  mix  the  blood  with  the  lymph,  for  if 
this  be  done  the  lymph  should  not  be  used.  It  is  best  to 
wait  a  minute  or  two  before  we  endeavour  to  take  lymph 
either  on  the  lancet  or  in  tubes  or  points,  and  having 
waited,  it  will  be  found  that  the  blood  has  coagulated,  and 
may  then  be  removed  on  the  point  of  the  lancet  without 
mixing  with  the  rest  of  the  lymph. 

The  next  step  is  to  attend  to  the  child  that  has  to  be 
vaccinated.  The  left  arm  is  the  one  usually  selected,  and 
it  is  the  one  most  convenient  for  the  vaccinator.  The  arm 
should  be  taken  out  of  the  sleeve,  and  held  in  the  left  hand 
of  the  vaccinator,  between  his  fingers  and  thumb.  This 
gives  him  a  firm  hold  of  the  child's  arm,  and  he  is  not  so 
likely  to  be  interrupted  by  a  hysterical  mother  during  the 
performance  of  the  act.  It  also  enables  him  to  blanch  the 
skin  of  the  arm  where  he  is  about  to  vaccinate  by  drawing  it 
tight  between  his  fingers  and  thumb,  and  thus  preventing 
bleeding  taking  place  during  the  act ;  and,  lastly,  it  drags 
the  incisions  apart,  and  allows  the  lymph  to  touch  the 
fresh-cut  surface.  The  lancet  should  be  blunt,  and  the 
incision  made  obliquely.  The  blunt  lancet  is  preferred 
because  it  tears  rather  than  cuts  the  capillaries,  and  a  torn 
vesicle,  as  every  surgeon  knows,  bleeds  less  than  a  cut  one. 
The  incision  is  made  obliquely,  because  the  portion  of  the 
skin  that  the  first  changes  occur  in,  as  has  before  been 
stated,  is  the  middle  layer  of  the  rete  Malpighii,  and  an 


72        THEORY  AND  PRACTICE  OF  VACCINATION 


oblique  incision  exposes  a  larger  area  of  this  than  a  per- 
pendicular one.  An  oblique  incision  also  causes  less 
bleeding  than  a  perpendicular  one.  The  lancet  used  for 
vaccination  should  never  be  used  for  any  other  purpose. 
It  should  be  dipped  in  water  after  each  vaccination,  and 
wiped  upon  a  clean  towel.  It  is  also  a  good  plan  to  heat 
it  in  a  spirit-lamp  before  commencing  the  day's  vaccination 
and  chilling  it  in  water.  This  method  does  not  improve 
the  appearance  of  the  lancet,  but  it  is  a  very  effective 
means  of  disinfecting  the  instrument.  The  lymph  is  taken 
from  the  vaccinifer  on  one  side  of  the  lancet,  and  should 
cover  its  tip ;  the  side  of  the  instrument  which  is  free  from 
lymph  should  be  the  side  next  the  skin  while  cutting ;  the 
blade  of  the  lancet  should  be  turned  on  the  handle,  so  that 
it  is  at  right  angles  with  it,  and  the  upper  part  of  the 
blade  is  to  be  held  between  the  thumb  and  middle  ringer, 
with  the  forefinger  on  the  angle  made  by  the  blade  and 
handle.  The  little  and  ring-fingers  should  rest  on  the  arm 
to  be  vaccinated,  and  the  cuts  made  upwards,  and  the 
lymph  placed  on  the  cuts  and  gently  pressed  in  with  the 
flat  of  the  instrument.  "When  well-selected  lymph  is  used, 
and  after  very  little  practice,  it  will  be  found  that  at  least 
94  per  cent,  of  the  insertions  of  the  lymph  are  successful. 
Our  own  insertion  success  with  humanized  lymph,  directly 
from  arm  to  arm,  for  the  last  twenty-two  years  at  St. 
Thomas's  Hospital  and  Surrey  Chapel  was  96*18  per  cent., 
there  being  9,011  cases. 

It  will  be  convenient  here  to  refer  to  the  so-called  in- 
susceptibility of  individuals  to  vaccination,  and  we  cannot 
do  better  than  quote  a  note  of  the  late  Medical  Officer  of  the 
Local  Government  Board,  Sir  George  Buchanan.  It  is  as 
follows : 

'  The  following  passage  (from  Medical  Officer's  1887  Beport) 
contains  the  experience  of  Dr.  Cory,  as  to  what  is  called 
'  insusceptibility  '  of  children  to  vaccination  : 

1  "  In  accordance  with  your  wish  that  I  should  record  my 
experience  of  vaccinating  children  who  have  been  certified 


THE  PRACTICAL  DETAILS  OF  VACCINATION 


73 


as  1  insusceptible,'  I  have  to  inform  you  that  at  various 
times  four  such  cases  have  been  sent  to  me  at  Surrey 
Chapel,  and  five  to  Lamb's  Conduit  Street,  and  that  in 
every  such  case  my  first  attempt  at  vaccination  has  suc- 
ceeded. The  resulting  vesicles  (whether  done  with  human 
or  with  calf  lymph)  have  been  quite  characteristic  of  vaccine, 
but  eight  of  them  were  accelerated  in  their  course  in  the 
same  way  that  I  have  observed  after  a  first  unsuccessful 
operation  by  myself. 

'  "  Of  my  own  vaccinations,  I  may  say  that  I  have  in  my 
time  performed  over  38,000  primary  operations  with  human 
or  with  calf  lymph,  and  that  it  has  only  once  fallen  to  my  lot 
to  fail  twice  at  an  attempt  at  vaccination.  The  subject  in 
this  instance  was  a  ten-year-old  child,  in  whom,  as  stated 
by  its  mother,  vaccination  had  been  attempted  on  previous 
occasions  without  result.  My  operation  failed  at  the  second 
attempt,  and  I  did  not  get  the  opportunity  of  trying  a  third 
time. 

4  "I  believe  the  late  Dr.  Marson  has  recorded  an  identical 
experience  from  several  thousands  of  operations  performed 
at  Blackfriars  Station,  where  humanized  lymph  only  was 
used."* 

'  Dr.  Cory  has  since  furnished  the  Medical  Department 
with  further  details  as  to  his  failures,  complete  and  partial. 
They  are  all  based  upon  experience  of  primary  vaccinations 
with  unstored  lymph,  each  operation  being  performed  by 
five  superficial  scratches. 

'  Among  some  16,000  first  attempts  at  vaccination  with 
humanized  lymph,  he  has  had  fourteen  failures,  being  at  the 
rate  of  one  failure  in  1,140  children  operated  on. 

'  Of  22,041  first  attempts  at  vaccination  with  calf  lymph, 
he  sets  aside  44  cases  vaccinated  (successfully)  for  the  cure 
of  naevi,  and  216  others  that  did  not  return  for  inspection. 

*  '  I  may  properly  point  out  that  Dr.  Cory  does  not  here  claim  for 
himself  any  exceptional  skill  above  his  fellows.  Reporting  on  his 
insertion  success  at  the  Animal  Vaccine  Station,  again  he  tells  of  one 
of  his  colleagues  getting  results  like  his  own,  but  a  trifle  better,  during 
consecutive  years.' 


74        THEORY  AND  PRACTICE  OF  VACCINATION 


Among  the  21,781  vaccinated  on  their  arms  with  calf 
lymph,  he  has  experienced  70  failures  at  a  first  attempt, 
being  at  the  rate  of  one  failure  in  311  children  operated  on. 

'  The  vaccinations  of  this  latter  class — those  from  the 
calf — were  therefore  distinctly  more  difficult  than  those 
done  from  arm  to  arm.  It  is  to  this  more  difficult  class 
that  the  following  figures  relate  : 

Five  insertions  succeeded  in  19,925  instances. 

Four       „  „  1,011 

Three      „  „  407 

Two        „  „  224 

One        „  „  144 

All  insertions  failed  in  70  ,, 

'  It  would  appear  from  the  above  and  other  similar  con- 
siderations that  total  failure  in  primary  vaccination  is 
explicable  without  recourse  to  any  hypothesis  but  that 
which  suffices  to  explain  partial  failure ;  and  this  cannot, 
by  the  nature  of  the  case,  be  an  "insusceptibility  "  in  the 
true  sense  of  the  word. 

'  Nevertheless,  there  is  a  so-called  "  insusceptibility,"  with 
which,  for  practical  purposes,  vaccinators  are  concerned, 
namely,  failure  to  obtain  any  vaccine  vesicle  in  a  given 
child  after  three  several  attempts  at  vaccination.  This 
failure  constitutes  a  statutory  "  insusceptibility,"  and  it  is 
desired  to  estimate  in  the  present  note  how  frequently 
a  "certificate  of  insusceptibility,"  in  this  sense,  is  to  be 
expected  from  one  and  another  class  of  operator. 

'  It  has  to  be  premised  that  a  second  attempt  at  vaccina- 
tion of  the  same  child  is  not  quite  so  likely  to  succeed  as  a 
first  attempt,  and  a  third  attempt  is  not  quite  so  likely  to 
succeed  as  a  second.  If  it  were  not  for  this  consideration, 
the  probability  of  failure  after  three  attempts  would  be  once 
out  of  xs  cases,  where  x  =  the  number  of  cases  yielding  one 
failure  at  a  first  attempt.  But  with  allowance  for  the 
differing  probability  of  success  at  repeated  attempts  to 
vaccinate,  we  must  expect  a  failure  at  a  third  attempt 
to  occur  more  often  than  once  out  of  x*  cases.    If  we  can 


THE  PRACTICAL  DETAILS  OF  VACCINATION  75 


learn  how  much  more  often,  we  shall  be  able  to  foretell  the 
probability  of  failure  at  a  third  attempt  in  the  practice  of 
any  vaccinator  for  whom  the  quantity  x  is  known. 

'  There  are  certain  American  experiences*  which  go  to 
show  the  probability  of  failure  at  a  third  attempt  to  be 
once  out  of  two-ninths  of  xs ;  and  there  are  some  German 
experiences*)"  which  would  place  it  at  once  out  of  one-ninth 
of  Xs.  There  are  no  English  experiences  available  for  such 
an  estimate. 

'  Let  us  first  use  the  assumption,  derived  from  American 
experiences,  that  the  probability  of  failure  at  a  third  attempt 
is  once  out  of  two-ninths  of  xs. 

-  Now,  on  the  scale  of  success  attained  by  Dr.  Cory  when 
vaccinating  with  calf  lymph,  x  =  311,  and  2#3-f-9  =  6,684,495, 
and  this  would  be  the  number  of  children  who  would  be 
expected  to  furnish  one  child  "  insusceptible "  in  the 
statutory  sense  of  the  word.  With  humanized  lymph,  in 
Dr.  Cory's  practice,  the  number  #  =  1,140,  and  2.x,3-^-9  = 
329,232,000,  this  being  the  number  of  children  who  would 
be  expected  to  furnish  one  child  "  insusceptible "  in  a 
statutory  sense. 

'  Or,  on  a  lesser  scale  of  success  (one  that  a  practitioner, 
when  vaccinating  from  arm  to  arm,  may  reasonably  look  to 
attain) — say  not  more  than  one  failure  per  100  children 
submitted  to  operation,  we  should  have  #  =  100,  or  2.r3-i-9 
=  222,222,  as  the  number  of  children  who  would  be  ex- 
pected to  furnish  one  "  insusceptible  "  child  among  them. 

'  Or,  if  a  vaccinator's  scale  of  success  were  so  unsatis- 
factory that  out  of  20  attempted  vaccinations  he  habitually 
experienced  one  failure  at  the  first  attempt,  it  would  be 
expected  that  a  "certificate  of  insusceptibility"  might  be 
given  as  often  as  once  for  every  1,778  children  presented  to 
him  for  vaccination  ;  but  such  a  5  per  cent,  of  first  failure 

*  Fifth  and  Sixth  Eeports  of  the  Board  of  Health  for  New  York, 
p.  120. 

f  Uebersicht  der  Ergebnisse  des  Impfgeschaftes  im  Deutschen 
Keiche  fur  1882,  pp.  8,  9,  16,  17,  24,  25,  in  the  Eeport  of  the  German 
Vaccination  Commission  of  1884. 


76         THEORY  AND  PRACTICE  OF  VACCINATION 


is  only  to  be  witnessed  in  the  practice  of  those  who  vaccinate 
unskilfully,  or  to  an  undue  extent  with  preserved  lymph. 
A  scale  of  failure  amounting  to  once  in  every  ten  first 
attempts  cannot  but  be  regarded  as  inexcusable ;  on  that 
scale,  the  frequency  of  certificates  of  "insusceptibility" 
would  be  once  in  222  cases  submitted  to  vaccination. 

'  From  the  above  calculations,  based  on  the  assumption 
derived  from  American  experience,  let  us  pass  to  examine 
the  question  on  the  basis  of  the  German  experience,  accord- 
ing to  which  the  probability  of  failure  at  a  third  attempt  is 
once  out  of  one-ninth  of  a?;  and  this  would  be  the  number 
to  give  one  instance  of  what  is  here  called  "  statutory 
insusceptibility." 

'  Then,  on  Dr.  Cory's  scale  of  success,  he  would  not  have 
more  than  one  "insusceptible"  out  of  every  3,342,247 
children  whom  he  vaccinated  with  calf  lymph,  or  more  than 
one  out  of  every  164,616,000  children  whom  he  vaccinated 
with  human  lymph.  On  the  next  scale  of  success,  a  practi- 
tioner, having  at  his  first  attempt  one  per  cent,  of  failure, 
might  expect  one  "  insusceptible "  case  out  of  111,111 
primary  vaccinations.  And  on  the  unsatisfactory  scale 
above  considered,  where  there  were  no  less  than  five  per 
cent,  of  failures  at  the  first  attempt,  a  vaccinator  would  be 
expected  to  certify  one  case  as  "insusceptible"  out  of  889 
children  submitted  to  him ;  while  on  the  extravagant  scale 
of  one  failure  out  of  every  ten  first  attempts  the  statutory 
"  certificate  of  insusceptibility  "  would  be  given  once  out  of 
111  operations.' 

Lymph  is  preserved  in  two  ways  at  the  present  time  in 
England.  Firstly,  in  capillary  glass  tubes,  and  secondly, 
on  ivory  points.  We  will  consider  first  how  the  lymph  is 
introduced  into  the  glass  tubes.  The  vaccine  vesicles  are 
pricked  in  about  twenty  places  towards  their  margins,  and 
after  waiting  a  minute  or  two  the  lymph  oozes  out  and 
collects  in  small  drops  on  the  vesicle.  One  end  of  the  tube 
is  applied  to  the  drop,  and  it  enters  by  capillary  attraction. 
If  the  tube  be  held  perpendicularly  the  force  of  capillary 
attraction  will  only  cause  it  to  enter  about  one  inch  in  a 


THE  PRACTICAL  DETAILS  OF  VACCINATION  77 


tube  of  average  bore,  but  if  the  tube  be  held  downwards  so 
as  to  allow  the  force  of  gravity  to  act  advantageously,  the 
tube  may  be  filled.  Two-thirds  of  the  tube,  however, 
should  only  be  filled,  and  when  this  amount  has  entered, 
but  not  before,  it  should  be  shaken  down  in  the  same  way 
as  an  index  of  a  thermometer,  by  striking  the  hand  in 
which  the  tube  is  held  against  the  other.  If  the  lymph 
is  shaken  down  before  all  has  entered,  the  column  of 
lymph  will  be  broken  up  by  intervening  air.  Having  got 
the  lymph  in  the  tube  and  shaken  it  down,  you  next  pro- 
ceed to  seal  the  ends  ;  this  is  best  done  by  the  aid  of  a 
spirit  lamp.  The  tube  is  held  by  the  finger  and  thumb  as 
far  towards  the  end  as  there  is  any  lymph,  so  that  the 
lymph  in  the  tube  is  prevented  from  being  heated.  First 
seal  the  wet  end — that  is,  the  end  by  which  the  lymph 
entered  ;  keep  the  glass  tube  red-hot  at  the  immediate  end 
without  melting  it,  so  that  the  tube  is  not  closed  until  the 
carbon  which  results  from  the  charring  of  the  lymph  has 
been  burned  off  the  immediate  end.  If  the  glass  be  melted 
before  this  has  taken  place  the  sides  of  the  tube  approach 
without  coalescing,  coalescence  being  prevented  by  the 
layer  of  charcoal,  and  it  is  then  quite  impossible  to  burn 
the  charcoal  off  because  the  air  cannot  gain  access  to  it. 
Having  closed  the  wetted  end  of  the  tube,  proceed  to  close 
the  other,  and  to  do  this  turn  the  other  end  of  the  tube 
towards  the  flame,  at  the  same  time  slipping  your  fingers 
and  thumb  towards  the  end  to  be  sealed,  so  as  to  protect 
the  lymph  from  the  flame  as  you  did  the  first  end.  Then 
quickly  pass  the  empty  portion  of  the  tube  through  the 
flame,  and  seal  immediately.  This  you  will  have  no 
difficulty  in  doing,  for  there  will  be  no  charring  of  the 
lymph,  this  being  the  dry  end.  It  will  now  be  evident 
why  the  wet  end  is  sealed  first,  for  if  we  drew  this  wet  end 
through  the  flame  the  whole  length  of  the  empty  part  of 
this  end  would  be  blackened. 

It  will  be  a  useful  preliminary  practice  to  try  a  few 
experiments  with  tubes.  Thus,  first  take  a  tube  and  seal 
one  end,  then  dip  it  in  the  ink-bottle — only  a  very  small 


78 


THEORY  AND  PRACTICE  OF  VACCINATION 


quantity  of  ink  can  enter,  for  if  the  ink  entered,  the  air 
inside  the  tube  would  be  compressed.  Now,  as  capillary 
attraction  is  a  force  by  which,  if  the  other  end  of  the  tube 
was  open,  the  ink  would  enter,  and  as  the  compressed  air 
would  be  a  force  in  the  opposite  direction  to  force  the  ink 
out,  the  ink  would  arrive  at  a  state  of  rest  as  soon  as  the 
two  forces  in  opposite  directions  balanced  one  another  ; 
but  as  the  force  of  capillary  attraction  is  a  weak  one,  it  is 
only  able  to  compress  the  air  in  the  tube  to  a  very  small 
extent,  therefore  the  ink  only  enters  for  a  very  short  dis- 
tance. Now  pass  the  tube  through  the  flame  of  a  spirit 
lamp,  and  rapidly  dip  the  open  end  again  into  the  ink.  As 
the  tube  cools  the  ink  will  rise,  for  by  drawing  the  tube 
through  the  flame  you  have  expanded  the  air,  and  you  can 
see  how  much  air  has  been  expelled  by  noticing  how  far 
the  ink  has  entered.  If  you  are  quick,  you  will  find  that 
about  half  of  the  air  in  the  tube  has  been  expelled. 

Now  take  another  tube,  seal  one  end  and  allow  it  to  cool, 
then  seal  the  other  end  without  drawing  any  portion  of  the 
tube  through  the  flame  ;  the  probability  will  be  that  a  little 
glass  bubble  is  produced  at  the  end  of  the  tube.  These 
two  little  experiments  will  show  you  the  rationale  of  the 
processes  just  advised  for  the  sealing  of  tubes.  There  is 
one  more  little  manoeuvre  that  is  useful  to  know.  Lymph 
often  coagulates  in  the  tubes,  and  when  you  have  broken 
both  ends  off  you  will  often  find  it  impossible  to  blow  it 
out  of  the  tube,  but  this  misfortune  may  always  be  avoided. 
Notice  which  end  of  the  tube  the  lymph  has  entered,  and 
before  you  have  broken  off  either  end,  pass  this  end  through 
the  flame  of  a  match,  being  careful  not  to  pass  any  of  the 
column  of  lymph  through,  for  a  comparatively  low  tempera- 
ture renders  the  lymph  inert.  The  steam  and  expansion  of 
the  air  caused  by  the  heat  of  the  flames  will  force  the  lymph 
towards  the  opposite  end,  and  thus  loosen  the  lymph  in 
the  tube.  You  can  now  break  off  the  ends  of  the  tube,  and 
the  lymph  will  be  easily  blown  out. 

About  ten  tubes  may  be  charged  from  the  arm  of  a  child 
vaccinated  in  five  places,  and  not  more.    There  is  often  a 


THE  PRACTICAL  DETAILS  OF  VACCINATION  79 


temptation  to  take  more  lymph  from  what  is  called  a  good 
yielding  arm,  but  the  lymph,  after  filling  ten  tubes  or  so, 
although  it  looks  clear  in  the  tubes,  is  not  so  active  as  that 
which  at  first  flows,  and  will  not  produce  such  successful 
results  on  other  children  it  may  be  used  for. 

Lymph  preserved  in  tubes  should  always  be  kept  in  a 
cool  place  away  from  the  light.  It  has  been  ascertained 
that  two  years  is  about  the  maximum  length  of  time  that 
it  will  keep  active.  It  loses  its  activity  gradually,, so  that 
the  insertion  success  becomes  less  and  less  as  the  age  of 
the  lymph  increases.  We  submit  the  following  table, 
which  gives  our  experience  during  the  period  1889  to 
August,  1893,  at  St.  Thomas's  Hospital  and  Surrey  Chapel 
with  humanized  lymph  as  used  only  by  ourselves  for 
primary  vaccination. 

Table  I. 

combined  success  of  humanized  tube  and  point  lymph 
used  at  st.  thomas's  hospital  and  surrey  chapel  during 
the  period  1889  to  june  30,  1893,  by  ourselves  for 
the  purposes  of  primary  vaccination  only.  tubes  89 
cases,  points  27  cases. 


Children,  Tube  Lymph. 


Different  periods  kept. 

Cases. 

Insertions. 

Successful. 

Per  cent. 

Under  10  days 

17 

85 

57 

67*06 

10  days  to  20  days 

9 

45 

25 

55-55 

20     „      50  „ 

9 

45 

29 

64-44 

50      „     100  „ 

37 

185 

130 

70-27 

100     „     150  „ 

6 

30 

22 

73-33 

150     „     365  „ 

11 

55 

20 

36-36 

2  days  to  365  days 

89 

445 

283 

65-39 

Children,  Point  Lymph. 

Under  10  days 

16 

80 

70 

87-5 

10  days  to  20  days 

5 

25 

14 

56-0 

20     „      50  „ 

6 

30 

16 

53-3 

50     „     100  „ 

2  days  to  44  days 

27 

135 

100 

74-4 

8o        THEORY  AND  PRACTICE  OF  VACCINATION 


With  regard  to  preserving  and  using  lymph  on  points, 
in  pricking  the  vesicles  to  take  lymph,  the  same  pre- 
cautions are  necessary  as  for  tube  lymph,  saving  that,  if 
blood  be  drawn  from  any  vesicle,  this  should  be  absolutely 
rejected,  for  it  is  impossible  to  examine  microscopically  the 
lymph  taken  on  points  for  blood  discs.  Especial  care  is 
likewise  incumbent  upon  the  medical  man  to  see  that  the 
vaccinifer  is  free  from  all  syphilitic  symptoms,  and  that 
the  vesicle  he  takes  lymph  from  is  quite  normal  in  appear- 
ance. Having  pricked  the  vesicle  in  several  places  towards 
the  margin,  the  lymph  soon  oozes  from  it,  and  it  is  taken 
up  on  the  tip  of  the  point  on  both  sides,  care  being  taken 
not  to  squeeze  the  vesicle,  but  only  to  take  that  lymph 
which  has  come  out.  A  good  yielding  arm  which  has  been 
vaccinated  in  five  places  should  serve  to  charge  about  forty 
to  fifty  points.  It  should  be  known,  however,  that  the 
first  lymph  which  flows  is  the  most  active.  A  vesicle 
which  continues  to  run  with  lymph  is  by  no  means  to  be 
exhausted,  as  the  last  lymph  which  flows  is  only  the  serum 
of  the  blood,  and  it  is  not  to  be  depended  upon  to  produce 
good  results  on  the  children  that  may  be  vaccinated  with  it. 

The  points  as  they  are  taken  should  be  laid  on  a  piece  of 
glass  with  ground  edges,  for  this  can  be  washed  after  it  has 
been  used  each  time,  and  thus  you  can  avoid  the  soiling  of 
the  points.  Keep  them  free  from  foreign  contamination. 
If  they  are  placed  upon  wood,  or  a  book,  it  often  occurs 
that  they  stick  when  dry  owing  to  a  wet  portion  of  the 
point  having  inadvertently  been  laid  upon  them,  and  when 
it  is  separated  a  portion  of  dirt  is  pulled  off  the  wood  or 
book  and  adheres  to  the  point.  The  points  are  usually 
made  from  ivory,  but  there  is  no  reason  why  other  sub- 
stances should  not  be  used.  It  has  often  struck  us  that 
white  vulcanite  or  celluloid  might  advantageously  be  used. 
To  use  the  points,  one  point  should  be  used  for  each  in- 
sertion of  lymph.  The  point  should  be  dipped  into  cold 
water.  All  the  superfluous  water  should  then  be  thrown 
off,  and  the  moistened  points  laid  on  a  piece  of  glass.  This 


THE  PRACTICAL  DETAILS  OF  VACCINATION 


81 


should  be  clone  before  proceeding  to  vaccinate  with  them. 
Next  have  the  individual's  arm  whom  you  are  about  to 
vaccinate  got  ready.  Let  the  arm  be  taken  out  of  the 
sleeve  as  before  described  on  page  71.  Hold  it  in  the  same 
manner  and  make  your  scarification.  Then,  without  letting 
the  arm  loose  from  the  left  hand,  proceed  to  rub  the 
lymph  off  the  moistened  point  over  one  of  the  scarifications, 
and  so  with  the  rest,  using  a  fresh  point  for  each  scarifica- 
tion. It  is  best  not  to  use  the  points  a  second  time  unless 
you  take  the  trouble  of  boiling  them  in  water  for  fifteen 
minutes,  which  may  be  conveniently  done  in  a  test-tube,  or 
in  a  kettle,  taking  care  that  the  water  boils  the  whole  time. 
They  should  then  be  dried  between  folds  of  clean  blotting- 
paper  and  put  by  in  a  clean  stoppered  bottle  for  future  use. 
They  should  on  no  account  be  put  in  the  waistcoat  pocket. 

The  maximum  length  of  time  the  points  will  keep 
active  is  about  three  months,  but  they  lose  their  activity 
with  age,  so  that  the  point  of  twenty  days  is  less  active 
than  that  of  two  days.  The  following  table  shows  our 
experience  of  them  as  kept. 

Table  II. — Animal  Lymph. 

RESULTS  OF  VACCINATION  OF  CHILDREN  WITH  CALF  LYMPH 
PRESERVED  ON  POINTS  AND  IN  TUBES  FOR  VARIOUS 
PERIODS. 


Mode  of 
storage. 


Points 


Tubes 


Time  during  which  lymph 
was  stored. 


Under  10  days 
10-20  days 
20-50  days 
50-100  days 
100-154  days 
Over  154  days 
Under  10  days 
10-20  davs 
20-50  days 
50-100  days 
100-154  days 
159-280  days 


Aggregate 
number  of 
insertions 
made  (5  to 
each  child). 


40 
25 
70 
70 
60 
30 
75 
25 
65 
45 
20 
40 


Aggregate 
number  of 
successful 
insertions. 


34 
21 
63 
51 
29 
0 
65 
17 
47 
39 
17 
33 


Percentage 
of  insertion 
success. 


85 
84 
90 
73 
48 
0 
87 
68 
72 
87 
85 
82 


6 


'82        THEORY  AND  PRACTICE  OF  VACCINATION 


Table  III. — Stored  Calf  Lymph  when  used  for  the 
Vaccination  of  Calves. 


Length  of  time  in 
days  during  which 
lymph  was  preserved 
in  tubes  before 

Number  of  insertions 
made  with  it  on 
calves. 

■■ 

Successful  insertions 
on  calves. 



Insertion  success 
rate,  percentage. 

using. 

2 

3,998 

3,390 

84-7 

4 

1,438 

1,139 

74*2 

6  to  8 

255 

184 

721 

9 

431 

309 

71-6 

11  to  12 

337 

273 

70-6 

14 

263 

214 

81-3 

16 

288 

207 

71-9 

17  to  46 

639 

472 

73-8 

53  to  93 

445 

332 

74-6 

100  to  200 

388 

258 

66-5 

200  to  500 

104 

17 

163 

500  to  600 

135 

45 

333 

600  to  700 

82 

24 

35-0 

816  to  858 

72 

4 

5'5 

In  comparing  the  table  on  pages  79  and  81  of  lymph 
preserved  in  tubes  with  that  of  lymph  preserved  on  points, 
it  will  be  noticed  that  whereas  the  tube  lymph  seems  to 
gain  in  activity  during  the  first  one  hundred  days  of  keep- 
ing, and  is  less  to  be  depended  upon  during  the  early  days 
of  its  preservation,  the  lymph  on  the  points  is  most  active 
during  this  period :  hence  the  rule  that  if  you  are  taking- 
lymph  to  use  immediately  or  within  a  month,  take  it  on 
points  ;  but  if  you  require  the  lymph  for  later  vaccinations, 
take  it  in  tubes.  Always  be  most  scrupulous  in  recording 
the  source  of  your  preserved  lymph.  This  is,  of  course, 
necessary  in  all  public  vaccinations,  but  it  is  as  morally 
obligatory  to  you  in  your  private  practice. 

Having  described  the  best  methods,  as  far  as  we  know, 
of  vaccinating  from  arm  to  arm,  and  with  preserved  lymph, 
we  will  next  consider  the  number  of  places  that  vaccination 
should  be  performed  in.  Evidence  has  been  collected  and 
reasons  given  on  pages  7  to  10  showing,  we  think,  the 
greater  benefit  that  is  derived  from  making  multiple  inser- 
tions, and  we  have  arrived  at  the  decision  that  five  separate 


THE  PRACTICAL  DETAILS  OF  VACCINATION  83 


vesicles  is  the  best  number  to  make.  That  one  large 
vesicle  having  an  equal  area  with  the  combined  areas  of  the 
separate  vesicle  is  not  equally  beneficial  we  consider  true 
from  the  side  both  of  practice  and  theory. 

In  a  report  of  a  committee  on  vaccination  to  the 
Epidemiological  Society,  published  in  vol.  v.,  new  series 
of  their  *  Transactions,'  p.  163,  the  committee  (consist- 
ing of  Mr.  Shirley  Murphy,  Dr.  John  MacCombie,  and 
the  author)  state  that  they  are  disposed  to  regard 
number  and  area  of  scars  as  by  no  means  convertible 
terms. 

The  following  consideration  will  also  help  to  settle  this 
question  : 

The  chemical  produced,  formed  by  the  growing  vesicle, 
is  absorbed  by  the  lymphatics,  and  thrown  ultimately  by 
the  circulation  all  over  the  body.  Now,  the  growing- 
portion  of  the  vesicle  is  its  circumference,  thus  the  circum- 
ference is  the  important  part  to  consider  and  not  the  area. 
If,  again,  as  there  is  every  reason  for  believing,  the  growing 
vaccine  is  a  form  of  ferment,  a  rough  analogy  will  help  to 
elucidate  this. 

The  fermentation  of  saccharine  solutions  is  brought 
about  by  an  organism  called  yeast.  While  this  organism  is 
growing  the  process  of  fermentation  goes  on,  and  the  sugar 
is  converted  into  alcohol,  but  as  soon  as  the  growth  is 
complete,  the  completed  growth  ceases  to  convert  the  sugar 
into  alcohol.  Indeed,  this  completed  growth  is  analogous 
to  the  completed  growth  of  the  vaccine  vesicle,  which  con- 
stitutes its  area.  In  the  growing  part  alone  is  the  product 
produced,  and  this,  as  before  said,  corresponds  to  the  cir- 
cumference of  the  vesicle.  Now,  the  circumference  of  a 
circle  is  slightly  more  than  three  times  the  length  of  the 
diameter,  viz.  3*14159,  but  it  may  be  taken  for  all  practical 
purposes  as  three  times  the  length  of  the  diameter;  hence, 
if  there  are  five  circles  of  10  mm.  diameter,  the  circum- 
ferences of  these  will  equal  (10  mm.  x  3)  5  =  150  mm.  in 
length,  and  150  mm.  circumference  will  equal  a  circle  whose 

6—2 


THEORY  AND  PRACTICE  OF  VACCINATION 


£  diameter  is  5 — '  =  50  mm.    To  re- 

o 

present  this  graphically  let  five  circles, 
each  of  a  diameter  of  10  mm.,  be  drawn 
inside  the  area  of  a  larger  circle,  A  B 
C  D,  having  a  diameter,  A  C,  of  50  mm. 
This  is  J  of  the  line  E  C,  which  repre- 
sents the  length  of  the  extended  cir- 
cumferences of  the  five  smaller  circles. 
The  circle,  AB  CD,  will  represent  the 
size  of  a  single  vesicle  which  would 
have  to  be  made  to  produce  the  effect 
-  of  the  five  smaller  vesicles.  It  is  ob- 
vious that  this  circle  is  greater  than 
the  combined  areas  of  the  smaller 
circles.   It  is,  in  fact,  five  times  larger. 

The  healing  of  a  vesicle  the  size  of 
the  larger  circle,  as  every  surgeon 
knows,  would  require  a  much  longer 
time,  and  while  healing  would  offer 
much  greater  facility  for  extraneous 
organisms,  such  as  erysipelas,  being- 
developed  upon  it,  than  the  five  smaller 
A  circles. 

There  can,  therefore, 
be  little  doubt  that  it  is 
better  to  vaccinate  in  a 
multiple  number  of 
places,  than  to  en- 
deavour to  make  one 
large  vesicle  equivalent 
to  the  smaller  ones. 

There  is  one  point 
further  we  may  learn 
from  the  tables  to  be 
found  on  pages  33  and 
54 :  we  can  see  that  the 


THE  PRACTICAL  DETAILS  OF  VACCINATION  85 


good  we  are  doing  by  increasing  the  number  of  cicatrices 
is  a  diminishing  one,  while  the  evil  that  we  are  doing  is  an 
increasing  one ;  so  that,  in  order  to  do  the  most  good,  we 
arrive  at  a  point  where  the  good  balances  the  evil.  Mr. 
Marson  was  of  the  opinion  that  the  greatest  amount  of 
good  with  the  least  amount  of  evil  was  arrived  at  when 
he  made  five  or  six  places.  We,  after  a  considerable  amount 
of  practice,  have  arrived  at  the  same  conclusion,  so  that  we 
consider  five  places  as  the  proper  number  to  vaccinate  in. 
Let  it  be  remembered  that  the  people  who  come  up  to  the 
public  vaccination  stations  are  usually  of  the  uneducated  class, 
which  are  numerically  the  chief  opponents  to  vaccination. 
These  people  will  only  have  their  children  once  vaccinated 
according  to  law.  It  is,  therefore,  incumbent  upon  us  as 
medical  men  to  give  them  that  kind  of  vaccination  which 
will  last  them  the  longest  time  with  the  least  amount  of 
evil,  and  we  have  said,  after  weighing  all  the  evidence  we  can 
collect,  that  five  is  the  proper  number  of  insertions  to  make. 
Among  the  educated  class  it  is  not  so  incumbent  upon  us 
to  make  the  larger  number  of  insertions,  because  there  is 
not  the  same  unreasonable  opposition  to  vaccination  as  in 
the  uneducated  class,  and  they  will  have  no  objection  to  re- 
vaccination  when  it  is  urged  upon  them ;  but  we  think  it 
right  to  insist  upon  the  five  places  among  this  class  also, 
because  the  better  educated  class  should  set  an  example  to 
those  who  are  less  fortunate. 

Now,  it  has  been  seen  that  vaccinations  performed  with 
preserved  lymph  are  not  nearly  so  successful  as  vacci- 
nations performed  with  perfectly  fresh  lymph  from  arm  to 
arm,  and  it  follows  that  we  should  vaccinate  as  far  as 
possible  from  the  more  active  kind  of  lymph.  In  a  large 
London  vaccination  station  it  is  possible  to  keep  up  a 
constant  supply  week  by  week  of  healthy  infants,  so  also  in 
large  country  towns  ;  but  in  the  small  places  a  weekly 
supply  of  healthy  children  cannot  be  maintained.  In  these 
latter  places,  therefore,  the  fresh  lymph  supply  will 
frequently  be  interrupted,  and  vaccination  from  preserved 
lymph  will  often  have  to  be  resorted  to. 


86        THEORY  AND  PRACTICE  OF  VACCINATION 


To  obviate  this  evil  as  far  as  possible,  it  has  been 
ordered  by  the  Local  Government  Board  in  those  dis- 
tricts where  the  vaccinations  are  too  few  to  ensure  a 
weekly  supply  of  fresh  lymph,  that  the  vaccinations  be 
done  periodically,  say  every  quarter.  The  first  two  or 
three  healthy  children  are  vaccinated  with  preserved  lymph, 
and  from  these  the  number  which  next  comes  up  to  the 
station  the  following  week  are  vaccinated.  It  will  at  once 
be  seen  that  this  arrangement  offers  the  minimum  amount 
of  vaccination  with  preserved  lymph.  This  regulation 
often  appears  irksome  to  those  who  have  not  reflected 
upon  it.  It  will  be  also  plain  that  the  regulation  enables 
the  vaccinator  to  generate  his  own  supply  of  lymph,  and 
this,  of  course,  is  most  desirable ;  for  otherwise  very  large 
demands  would  fall  upon  the  central  office  for  the  supply 
of  vaccine  lymph,  and  this  supply  would  be  largely  used  by 
lazy  practitioners,  to  the  detriment  of  the  vaccination  of  the 
community.  There  is  also  a  rule  insisting  that  all  children 
should  be  vaccinated  at  the  public  stations,  and  all  that 
have  been  so  vaccinated  should  be  inspected  at  the  same. 
This  regulation,  of  course,  obviates  the  evil  arising  from 
carrying  preserved  lymph  to  the  houses  of  patients  who  it 
may  be  wished  in  this  way  to  please. 

We  have  already  spoken  of  the  treatment  of  the  vesicle 
if  abnormal,  and  have  cautioned  against  the  use  of  shields 
(p.  45).  When  the  vesicle  is  normal  only  a  dry  piece  of 
clean  linen  rag  should  be  laid  over  it  and  secured  in  place 
with  a  few  stitches.  This  should  be  changed  morning  and 
night. 

Poultices  when  ignorantly  applied  not  only  cause  the  re- 
moval of  the  scab  before  its  time,  but  produce  auto-inocula- 
tion of  the  surrounding  skin. 

There  is  another  bad  practice  which  we  have  had  occa- 
sion to  witness  several  times,  and  that  is,  the  taking  the 
names  of  the  vaccinees  on  a  separate  piece  of  paper,  and 
entering  them  afterwards  in  the  register.  No  doubt  this 
practice  has  been  brought  about  by  the  laudatory  intention 


PLATE  XII. 


West  lie wrrLfiuii  lath 


PLATE  XIII. 


We  s  t  ,Ue  wrrLSLTi  lith. 


PLATE  XIV. 


Fig.l. 


Fiq.2. 


Xe/fc  h.ouvuL  ensX- 


P|  Fig  .  4-. 


■fl   =  

Table- as,  seen-  from  above  wvths  i-ox)  off. 


7Vest,Newxxxa.n  litL 


THE  PRACTICAL  DETAILS  OF  VACCINATION  87 


of  keeping  the  register  neat,  but  here  neatness  is  acquired 
at  the  expense  of  exactness,  and  the  register  had  rather 
be  exact  than  neat.  We  do  not  mean  to  imply  that 
neatness  is  not  to  be  aimed  at,  but  only  that  any  method 
by  which  neatness  is  acquired  should  not  be  one  where 
exactness  is  likely  to  be  sacrificed.  Always  have  the 
register  with  you,  and  enter  all  the  names  of  the  vaccinees 
present,  before  you  proceed  to  vaccinate.  It  will  then  be 
easy  to  enter  the  source  of  your  lymph  supply.  Always  be 
scrupulously  punctual  at  your  station;  be  firm,  yet  courteous, 
in  your  behaviour ;  and  insist  upon  vaccinating  in  the 
manner  you  consider  best.  We  should  always  remember 
that  it  is  our  duty  to  educate  our  patients  in  professional 
subjects,  not  for  them  to  educate  us. 

We  will  now  consider  the  modifications  of  practice  we 
have  to  exercise  in  animal  vaccination. 

First  of  all  let  us  consider  the  premises  and  construction 
of  an  ideal  station,  and  we  here  give  a  plan  of  such  for  a 
large  station  of,  say,  7,000  vaccinations  a  year. 

Secondly,  as  to  the  furniture  required.  For  the  waiting- 
room  about  200  wooden-bottomed  chairs,  with  an  equal 
number  of  wooden  stools  for  nursing  mothers  to  place  their 
feet  upon,  and  a  good-sized  table  to  place  packages,  etc., 
with  a  large  umbrella-stand,  and  perhaps  a  clock,  is  all  the 
furniture  requisite  in  this  room.  The  floors  are  best  made 
of  concrete,  without  carpet  or  other  covering. 

For  the  operating-room  two  tables  are  necessary,  but 
three  are  more  convenient  for  the  vaccination  of  the  calves, 
and  a  weighing-machine.  The  construction  of  these  tables 
is  shown  in  the  plan,  which  is  drawn  to  scale.  The 
tops  are  made  movable,  so  that  when  tilted  up  the  calf 
can  be  partially  secured  to  it  while  standing.  The  top  is 
then  turned  so  that  the  calf  lies  on  the  table.  The  man 
who  has  helped  to  turn  the  table  up,  and  is  now  placed  at 
the  back  of  the  animal,  seizes  the  uppermost  fore-leg  and 
bends  it  upon  itself,  holding  the  bent  limb  near  the  body 
of  the  beast.  •  This  manoeuvre  usually  renders  the  beast 


88        THEORY  AND  PRACTICE  OF  VACCINATION 


unwilling  to  struggle,  but  if  it  does  struggle  it  gives  the 
man  great  control  over  it.  The  head  is  then  secured,  and 
the  uppermost  hind-leg  is  immediately  afterwards  fastened 
to  the  iron  upright.  But  before  this  is  done  it  is  well  to 
wrap  a  piece  of  saddle  stuffing  round  the  leg  of  the  animal 
to  prevent  the  rope  and  the  iron  hurting  it.  The  fore-legs 
are  then  secured  by  the  leather  straps,  and  the  calf  is  ready. 
The  other  calf  is  then  similarly  prepared.  As  the  vac- 
cinated calf  will  be  retained  the  longer  on  the  table,  in 
order  to  obtain  the  vaccine  lymph,  it  is  humane  to  put 
this  one  on  the  table  last. 

The  calf  to  be  vaccinated  should  be  shaved  previously  from 
the  umbilicus  to  the  groin,  and  the  shaved  portion  of  the 
skin  washed  with  a  piece  of  sponge  soaked  in  a  solution  of 
perchloride  of  mercury,  containing  one  part  of  perchloride 
to  1,000  parts  of  water.  Two  or  three  grains  of  chloride  of 
ammonium  will  render  the  perchloride  of  mercury  more 
soluble,  so  this  salt  may  be  added.  The  vaccinated  animal 
should  also  be  washed  over  the  area  on  which  the  vesicles 
are  situated  with  the  same  lotion,  and  immediately  after 
the  lotion  with  clean  water.  (The  Fig.  shows  the  amount 
of  surface  shaved,  the  number  of  vesicles,  and  the  manner 
of  putting  on  the  forceps  to  obtain  the  lymph.)  After  the 
animal  is  vaccinated,  a  cradle  is  placed  on  its  neck  as  soon 
as  it  is  returned  to  its  stall.  The  cradle  is  to  prevent  the 
animal  from  licking  its  vaccinated  places. 

The  calves  should  be  well  fed  during  the  course  of  their 
vaccination  on  milk  and  hay.  The  milk  should  be  boiled 
and  allowed  to  cool  before  giving  it  to  the  calves.  This  is 
important,  especially  during  the  hot  weather,  as  it  prevents 
the  diarrhoea,  which  is  so  detrimental  to  the  development 
of  the  vesicles,  and  is  so  prevalent  among  the  calves  fed 
with  raw  milk  during  the  hot  season.  Upon  the  fourth 
day,  but  not  later  than  the  fifth  after  vaccination,  the 
lymph  can  be  taken  from  the  calves  to  vaccinate  other 
calves  or  children.  In  hot  weather  the  earlier  day  is  the 
better.    It  will  be  noticed  that  this  is  at  least  three  days 


THE  PRACTICAL  DETAILS  OF  VACCINATION  89 


earlier  than  it  is  customary  to  take  lymph  from  the  human 
infant,  which  is  the  eighth.  This,  indeed,  is  the  latest 
day  that  it  is  justifiable  for  taking  the  lymph  from  them. 
Lymph  taken  from  the  calf  later  than  the  fifth,  and  from 
the  human  infant  later  than  the  eighth,  is  not  to  be  de- 
pended upon,  for  often  it  will  produce  sores,  if  any,  which 
are  not  protective  against  further  vaccination,  as  in  the 
human  infant,  which  has  already  been  shown  (p.  57).  One 
reason  of  the  more  rapid  development  of  the  vesicles  on  the 
calf,  probably,  is  the  higher  temperature  of  the  young  animal 
than  of  the  human  infant,  the  normal  temperature  of  the 
former  being  102*63°,  whereas  that  of  the  latter  is  only 
98*87°,  the  difference  being  3'76°  higher  in  the  calf.  The 
chart  will  show  the  relative  temperatures  of  the  two  animals 
during  the  course  of  vaccination. 

It  will  be  noticed  that  the  maximum  temperature  occurs 
on  the  seventh  day  in  the  human  infant,  whereas  it  occurs 
on  the  fourth  or  fifth  day  in  calves,  and  this  latter  fact 
corresponds  with  the  earlier  clay  on  which  the  lymph  is 
better  taken  from  these  animals.  It  is  as  important  to  use 
the  lymph  taken  directly  from  the  calf  to  perform  vaccina- 
tion on  another  calf  or  on  children,  as  it  is  to  use  the 
human  lymph  taken  directly  from  another  arm.  When  it 
is  necessary  to  preserve  animal  lymph,  it  is  customary  to 
take  it  either  on  points  or  tubes.  The  same  rules  as  obtain 
in  the  use  of  human  preserved  lymph  are  applicable  to  the 
use  of  animal  lymph.  If  vaccinations  are  to  be  performed 
with  preserved  lymph  during  the  first  fortnight  of  its  pre- 
servation, the  lymph  should  be  taken  on  points ;  if  longer, 
then  tubes  will  give  the  better  result.  In  using  calf  lymph 
in  tubes  it  is  best  to  blow  out  the  contents  of  five  or  six 
tubes,  and  mix  them  altogether. 

The  foregoing  tables  show  the  relative  keeping  power  of 
the  lymph  as  used  for  the  vaccination  of  calves  or  infants. 
A  register  should  always  be  kept  of  the  names,  the 
addresses,  the  age,  the  sex,  the  number  of  places  vaccinated, 
the  number  of  successful  places,  the  source  of  the  lymph 


90  THEORY  AND  PRACTICE  OF  VACCINATION 

Chart  A. 

SHOWING  TEMPERATURE  OF  VACCINATED  CALVES. 

[The  continuous  line  represents  the  temperature  of  males,  the  intercepted 
line  that  of  females.'] 


Days  of  Vaccination. 


0 

1st. 

2nd. 

3rd. 

4th.        5th.  6th. 

7th.    j    8th.  | 

eth.  | 

10th.  | 

Huh.  1 

N 

— 

\ 

-  5 

103  0 
•9 

•a 

■7 

■6 
5 

•4 
3 
2 

•/ 

102  0. 


Chart  B. 

SHOWING  THE  TEMPERATURE  OF  VACCINATED  INFANTS. 

[As  regards  day  of  vaccination,  temperature  taJcen  after  performance  of 

the  operation.'] 


Tern  p. 
Fahren 
beit. 


Days  of  Vaccination. 


0 

1st.    J    2nd.  3rd. 

4th 

6th. 

Bih. 

7th. 

8th. 

9th. 

10th. 

nth. 

/ 

\ 

/ 

\ 

55- 

/ 

/ 

\ 

/ 

THE  PRACTICAL  DETAILS  OF  VACCINATION  91 


used,  and  the  date  of  inspection.  The  register  should 
always  be  with  you  while  vaccinating,  so  that  the  names 
be  entered  at  the  time,  and  the  source  of  the  lymph  re- 
corded. You  should  arrange  for  all  those  infants  who  have 
been  vaccinated  to  come  back  on  the  day  week  to  the 
station,  and  it  is  very  useful  to  make  some  record  of  the 
condition  of  the  arm.  This  is  conveniently  done  by  a 
small  diagram  such  as  this,  i>    ,  where  a  repre- 

sents the  average  size  of  the  vesicle,  and  b  represents  the 
extent  of  the  areola,  if  any,  on  the  eighth  day. 

You  should  on  no  account  take  the  lymph  to  your 
patient's  house,  because  you  will  necessarily  be  using 
preserved  lymph,  and  this  should  never  be  used  when  it 
can  be  avoided,  for  failure  is  so  much  more  frequent  after 
its  use.  All  to  be  vaccinated  ought  to  be  made  to  come  up 
to  the  station  at  an  appointed  hour  on  a  certain  day,  or 
days,  of  the  week,  and  the  vaccinations  performed  either 
from  arm  to  arm  or  from  calf  to  arm.  If  the  number  of 
cases  in  a  given  district  be  too  small  to  keep  up  a  regular 
weekly  supply  of  fresh  lymph,  periodical  vaccinations  then 
are  the  best,  for  the  first  one  or  two  cases  can  be  done  with 
preserved  lymph  and  the  rest  from  successful  cases  of  the 
first  one  or  two. 

The  following  observations  may  be  made  during  the 
course  of  a  primary  human  vaccination : 

Days  of  Vaccination. 
First. 

Notice  in  some  cases,  when  first  vaccinated,  the  skin  at 
the  parts  scratched  immediately  seems  raised ;  this  is  due 
to  a  provoked  urticara,  and  is  indicative  of  the  tendency  of 
the  skin  to  this  eruption. 

Second. 

Notice  the  slight  redness  at  the  parts  scratched,  and  that 
they  are  as  yet  level  with  the  general  surface  of  the  skin. 


92        THEORY  AND  PRACTICE  OF  VACCINATION 


The  temperature  of  the  individual  is  scarcely,  if  at  all, 
raised. 

Third. 

Notice  that  the  redness  has  slightly  increased,  and  that 
the  parts  inoculated  feel  shotty.  The  temperature  is  a  little 
raised. 

Fourth. 

The  redness  has  still  further  increased ;  the  points  of 
inoculation  not  only  feel  shotty,  but  are  slightly  raised, 
and  are  generally  commencing  to  be  vesicular.  The 
temperature  is  slightly  higher  than  on  the  third  day. 

Fifth. 

Notice  that  the  inoculated  places  are  distinctly  vesicular. 
The  temperature  remains  nearly  the  same  as  on  the  fourth 
day. 

Sixth. 

The  vesicles,  which  now  appear,  are  more  or  less  distinct, 
several  of  them  being  crowded  over  each  area  of  inocula- 
tion.   The  temperature  is  further  slightly  raised. 

Seventh. 

Many,  if  not  all,  the  vesicles  which  were  crowded  over  an 
inoculation  area  have  become  confluent.  The  temperature, 
comparatively,  is  much  higher,  and  has  reached  its  maximum, 
i.e.,  about  J°  C.  above  the  normal. 

Eighth. 

This  is  the  usual  day  for  taking  the  lymph.  It  may  be 
taken  before,  but  not  after.  The  areola  begins  to  form, 
but  it  never  should  be  excessive.  The  temperature  falls  a 
little  more  than  it  rose  on  the  seventh  day. 

Ninth, 

The  areola  is  now  at  its  height.  The  temperature  again 
rises  a  little. 


THE  PRACTICAL  DETAILS  OF  VACCINATION  93 


Tenth. 

The  areola  is  still  extensive,  and  is  not  declining.  The 
centre  of  the  vesicle  is  undergoing  change,  and  the  vesicles 
are  themselves  at  their  maximum  size.  The  temperature 
has  fallen. 

Eleventh, 

The  areola  is  fast  declining,  and  the  alteration  in  the 
appearance  of  the  centre  of  the  vesicle  is  more  marked, 
and  extending  centrifugally. 

Twelfth. 

The  areola  has  almost  quite  faded,  and  the  scab  is 
gradually  drying  from  the  centre  towards  the  circumference. 

Twenty-first. 

The  scabs  usually  fall  on  this  day,  leaving  healthy 
cicatrices,  unless  they  have  been  interfered  with  by 
poultices  or  ointments. 

Concerning  Ee-vaccinations,  etc. 

Hitherto  there  has  been  no  satisfactory  classification  of 
these  adopted.  One  author  will  give  a  large  percentage  of 
these  as  unsuccessful ;  another  will  give  a  far  less  per- 
centage, depending  upon  what  one  and  another  regards  as 
successful  in  the  various  manifestations  of  the  sore  pro- 
duced by  a  re-vaccination.  The  following  is  an  endeavour 
to  give  some  scientific  classification  which  shall  be  regular 
in  its  working  amongst  different  observers. 

The  following  classification  has  been  adopted  at  the 
animal  vaccine  establishment  since  its  commencement. 

Classification  of  Ke-vaccinations. 

(0)  are  those  cases  on  whom  re-vaccination  produces  no 
results. 

(1)  are  those  cases  on  whom  there  is  scarcely  any  areola, 
and  the  sore  does  not  advance  after  the  fourth  day,  and 
never  becomes  truly  vesicular. 


94 


THEORY  AND  PRACTICE  OF  VACCINATION 


(2)  are  those  cases  which  do  not  advance  after  the  sixth 
day,  become  vesicular,  and  have  a  moderately  extensive 
areola,  which  has  declined  by  the  eighth  day.  On  this  day 
the  scabs  are  darkening. 

(3)  are  those  cases  on  whom  there  has  been  a  more  or  less 
extensive  areola,  which  is  declining  on  the  eighth  day  ;  by 
this  day,  also,  the  vesicles  are  fully  formed,  and  only 
slightly,  if  at  all,  darkening. 

(4)  are  those  cases  on  whom  the  areola  is  at  its  height  on 
the  eighth  day. 

(5)  are  those  cases  on  whom  the  areola,  though  present, 
has  not  attained  its  height  on  the  eighth  day. 

(6)  are  those  cases  resembling  in  all  respects  primary 
vaccination. 

The  following  Tables  IV.  and  V.  have  been  drawn  up, 
showing  the  practical  results  of  the  classification  adopted. 

Table  IV.  contains  those  cases  which  have  been  once 
previously  vaccinated,  and  Table  V.  contains  those  cases 
which  have  been  more  than  once  previously  vaccinated. 

In  Table  IV.,  column  1,  are  given  the  characteristic 
numbers  of  the  classification.  In  column  2  the  number 
of  cases  which  fall  under  the  different  characteristics  is 
given  ;  in  column  3  the  range  of  ages  is  given  ;  in  column 
4  the  aggregate  age  of  all  the  cases  under  the  specified 
characteristics  is  given,  and  the  aggregate  age  divided  by 
the  number  of  cases  in  column  2  will  give  the  average  age 
of  those  re- vaccinated,  and  they  are  given  in  column  5. 

In  order  to  form  an  approximate  estimate  of  the  pro- 
portion of  cases  which  are  more  or  less  influenced  by 
other  causes  than  by  the  lapse  of  time,  it  is  necessary  to 
form  some  idea  of  the  age  of  presumably  normal  cases, 
i.e.,  those  on  whom  time  alone  influences  the  return  to 
susceptibility. 

Now,  it  will  be  seen  on  reference  to  Table  IV.,  column  5, 
that  18*08  is  the  average  age  at  which  all  are  re-vaccinated, 
and,  further,  that  18  is  the  age  at  which  those  in  the  mean 
characteristic,  or  No.  3,  are  re-vaccinated.   It  may  therefore 


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96        THEORY  AND  PRACTICE  OF  VACCINATION 


be  inferred  that  No.  3  contains  very  few,  if  any,  of  the 
abnormal  cases.  It  may  also  be  inferred  that  the  two 
characteristics  on  either  side  of  3,  i.e.,  characteristics  Nos.  2 
and  4,  will  contain  fewer  of  the  abnormal  cases  than  those 
more  remote  from  3 ;  yet  we  may  safely  assume  that  they 
will  contain  some.  No.  2  is  *95  less  than  18,  and  No.  4  is 
•59  greater  than  18,  or  on  an  average  *77  difference ;  the 
allowance  must  be  made  for  the  abnormal  cases  they 
contain.  Let  it  be  assumed  that  the  figure  *77  may  be 
taken  as  2,  and  let  it  also  be  assumed  that  the  charac- 
teristics are  regular,  i.e.,  they  represent  equal  increments 
of  time  that  would  elapse  before  each  consecutive  charac- 
teristic would  be  reached  on  the  return  to  susceptibility. 
Then,  on  making  additions  of  2  to  18  as  the  characteristic 
numbers  ascend,  and  deductions  of  2  as  they  descend,  we 
get  20,  22  and  24  on  the  one  hand,  and  16,  14  and  12  on 
the  other.  These  may  be  called  hypothetical  ages,  and 
they  are  given  in  column  6.  From  the  above  considera- 
tions it  follows  that  if  time  alone  had  to  be  considered,  an 
individual  is  by  a  single  infantile  vaccination  rendered 
immune  to  further  vaccination  for  fourteen  years.  As  6 
represents  the  re-vaccination,  which  resembles  in  all  respects 
a  primary  vaccination,  the  individuals  which  have  the 
greatest  tendency  to  return  to  their  susceptible  condition 
will  be  collected  together  under  this  class.  They  may  be 
called  unstable  with  respect  to  their  former  vaccination. 
The  number  of  the  unstable  individuals  will  gradually 
diminish  in  the  characteristic  as  No.  3  is  approached. 

Again,  as  0  represents  that  no  result  follows  re- 
vaccination,  all  the  individuals  which  have  an  opposite 
tendency  to  those  just  mentioned,  and  who  may  be  called 
the  stable  individuals,  will  be  collected  under  that  character- 
istic. These,  it  may  be  inferred,  will  gradually  diminish  as 
No.  3  is  approached.  The  unstable  individuals  will  tend 
to  diminish  the  average  age,  while  the  stable  individuals 
will  tend  to  increase  it  to  what  it  would  have  been  if  time 
alone  had  to  be  considered. 

In  characteristics  Nos.  6,  5,  and  4,  containing  as  they  do 


THE  PRACTICAL  DETAILS  OF  VACCINATION  97 


the  majority  of  the  unstable  class,  this  unstable  class  must 
be  subtracted  in  order  to  raise  the  average  up  to  the  hypo- 
thetical ages  ;  but  in  characteristics  Nos.  2,  1,  and  0,  con- 
taining the  stable  class,  unstable  cases  must  be  added  in 
order  to  bring  down  the  average  to  the  hypothetical  age. 
For,  as  we  have  just  said,  the  inclusion  of  unstable  cases 
diminishes  the  average  age,  5*59  years  being  the  average 
interval  which  elapses  between  one  re-vaccination  and 
another,  as  given  in  Table  V.,  column  5a.  And  as  we  may 
fairly  assume  the  cases  under  this  characteristic  are,  the 
vast  majority  of  them,  stable  individuals,  we  may  approxi- 
mately take  5*59  years  as  the  average  period  during  which 
the  stable  individuals  enjoy  immunity. 

From  the  above  data  we  can  formulate  the  following 
equation  for  characteristic  6. 

Let  x  represent  the  number  of  unstable  individuals, 
which  must  be  subtracted  from  the  number  in  column  2, 
i.e.  156,  in  order  that  the  average  age  given  in  column  5, 
i.e.  17'91,  may  be  brought  up  to  the  hypothetical  age  given 
in  column  6,  i.e.  24. 

Hence  x  x  5*59  {i.e.,  x  multiplied  by  the  average  period 
during  which  the  stable  individuals  have  immunity,  for 
this  at  most  must  be  the  longest  average  time  that  unstable 
individuals  have  immunity)  will  give  approximately  the 
aggregate  age  of  the  unstable  individuals ;  and  if  we  take  the 
number  from  2806* 3,  the  aggregate  age  of  all  the  cases 
given  in  column  4,  we  get  2806*3  — 5*59  x,  and  this  divided 
by  156,  the  total  number  of  cases  less  by  x,  will  give  us 
the  average  age  of  those  who  are  only  influenced  on  their 
return  to  susceptibility  by  time,  and  this  we  have  assumed 
to  be  24.  The  equation  will  therefore  stand  thus  for 
characteristic  6  : 

2806-3  -  5-59 

156-.*  ~24' 


2806-3  -  5-o9x  =  3744  -  24*. 
18-41*  =  937-7.    .-.  *  =  50-93. 


7 


98        THEORY  AND  PRACTICE  OF  VACCINATION 


The  equation  for  No.  5  will  be : 

7029-5-59, 


848 -a;  ~22- 

7029  -  5'59,  =  7656  -  22,. 
16-41,  =  627.    .-.  ,  =  38'23. 


The  equation  for  No.  4  will  be : 

18539-75-5-59, 


997-,  =20' 

18539-75  -  5-59,  =  19940  -  20,. 
14-41,  =  1400-25.    .-.  x  =  97-17. 


No.  3,  it  has  been  assumed,  contains  no  exceptional  cases. 

No.  2.  Here  we  have  to  add  unstable  cases  in  order  to 
diminish  the  average  age  and  make  it  equal  to  the  hypo- 
thetical age. 

Our  equation  for  this  characteristic  will  be : 

24938-7  +  5-59, 

1463  +  ,       ~  6* 

.-.  24938-7  +  5-59, -=23408  +  16,. 
.-.  ,  =  147*04. 


Similarly  the  next  equation  for  No.  1  will  be : 

7629  +  5  59, 
396  +  ,     ~  14' 

.*.  7629  +  5-59  =  5544  + 14,. 

.-.  8-41,  =  2085.    .-.  ,  =  247-92. 


Similarly  the  next  equation  for  characteristic  0  will  be  : 


1102  +  5-59,  =  -2 
53  +  , 

1102  +  5-59,  =  636  +  12,. 
6*41,  =  466.    .-.  ,  =  72-70. 


The  different  values  that  have  been  found  for  x  are  given 
in  column  7,  and  they  represent  the  number  of  exceptional 
cases  which  are  contained  under  the  different  characteristics, 


THE  PRACTICAL  DETAILS  OF  VACCINATION  99 


and  these  are  what  were  required  to  be  found.  It  will  be 
noticed  that  their  sum  is  653'99,  and  as  there  are  5,075 
cases,  the  percentage  of  exceptional  cases  will  be  12*89. 

In  column  8  the  percentages  that  the  calculated  numbers 
in  column  7  bear  to  the  number  of  cases  in  column  2  are 
given  under  their  respective  characteristics,  and  in  column  9 
the  percentages  that  the  calculated  numbers  in  column  7 
bear  to  the  total  number  of  cases — viz.,  5,075 — are  given. 

Table  V. — This  table  contains  those  cases  which  have 
been  more  than  once  previously  vaccinated.  Columns  2a, 
3a,  4a,  5a,  6a,  la,  8a,  and  9a  correspond,  giving  the  same 
details  as  columns  2,  3,  4,  5,  6,  7,  8,  and  9  do  in  Table  IV. 

The  equations  for  Table  V.  require  the  negative  sign 
throughout,  because  the  hypothetical  intervals  are  all  higher 
than  the  average  intervals.  It  will  also  be  noticed  that  the 
percentages  of  the  exception  cases  to  the  numbers  in 
column  2a,  which  are  given  in  column  Sa,  are  more  nearly 
equal  than  they  are  in  the  corresponding  column  8  in 
Table  IV.,  except  for  characteristics  6  and  0.  The  probable 
reasons  for  their  exception  will  presently  be  given.  The 
meaning  of  this  generally  greater  equality  of  the  per- 
centages in  column  8a  is  probably  that  the  element  of  time 
has  correspondingly  less  to  do  with  the  return  to  suscepti- 
bility in  the  cases  of  persons  who  have  been  more  than 
once  vaccinated  than  it  has  to  do  with  those  only  once 
previously  vaccinated  in  infancy.  If  this  be  so,  then,  since 
the  element  of  time  is  more  or  less  eliminated  for  those 
in  Table  V.,  there  can  be  no  reason  why  proportionally 
more  stable  individuals  should  be  re-vaccinated  at  the  later 
intervals  of  time  than  at  the  earlier ;  neither  should  there 
be  proportionally  more  of  the  unstable  individuals  re-vacci- 
nated at  the  earlier  intervals.  Hence,  the  proportion  of 
the  exceptional  individuals  to  the  number  of  cases  given  in 
column  2a  ought  to  be  about  the  same  if  the  registration 
under  the  different  classes  be  correct.  There  is  indeed 
sufficient  equality  to  show  that  registration  was  practically 
correct,  except,  as  has  been  said,  for  characteristics  6  and  0. 

7—2 


ioo       THEORY  AND  PRACTICE  OF  VACCINATION 


With  regard  to  characteristic  6,  it  can  be  seen  in  Table  V. 
that  there  are  only  five  out  of  1,113  cases,  or  only  0*45  per 
cent.,  and  it  is  more  than  likely  that  there  may  be  some 
whose  alleged  former  re-vaccination  was  not  really  success- 
ful. Then,  again,  with  regard  to  characteristic  0,  some  of 
the  cases  were  probably  successfully  re-vaccinated,  but  the 
re-vaccination  had  run  so  rapid  a  course  that  on  the  eighth 
day,  when  inspected,  it  was  considered  that  they  had  not 
taken ;  further,  those  individuals  who  are  judged  not  to 
have  taken  are  entered  as  fresh  re-vaccinations  in  the  register, 
and  nearly  always  the  same  results  happen  again  on  the 
next  eighth  day,  when  they  are  inspected.  As  these  cases 
are  vaccinated  three  times,  it  follows  that  the  number  of 
cases — viz.,  thirty-seven — ought  to  be  divided  by  three, 
which  would  leave  only  12*5  cases  out  of  1,113,  or  11*23 
per  cent.  That  the  registration  was  practically  correct  is 
further  borne  out  by  the  fact  that  there  really  were  two 
registrars :  one,  Mr.  Lapidge,  at  Southampton  Row,  who 
registered  333  cases ;  the  other,  Mr.  Adams,  at  95,  Lamb's 
Conduit  Street,  who  registered  780  cases.  Tables  VI.  and 
VII.  show  the  similarity  of  the  two  registrations  respectively, 
and  Table  VIII.  compares  the  two  comparable  columns. 

Column  10,  Table  V.,  contains  the  number  of  cases  which 
must  be  added  or  subtracted  from  the  calculated  numbers 
in  column  la  to  make  the  percentages  in  column  Sa  equal. 
The  calculation  is  thus  made :  Let  x  =  the  number  to  be 
added  or  subtracted  from  4'59,  so  as  to  make  the  per- 
centage in  column  8a  equal  to  68*7,  which  is  the  average 
percentage  in  column  8a. 

Thus,  for  No.  6  characteristic  the  following  equations 
can  be  formulated  : 

(4-59^^)100  =  68.7< 

5 

.-.  459  ±100*  =  343-5. 
.•.  x  =  ±  1*15  ;  and  by  trial  we  find  that  x  =  -  1'15. 

Similarly,  the  equation  for  No.  5  characteristic  will  be  : 

(2Q*;)ioo  =  68.7,  ,.X  =  +  V11. 

OO 


THE  PRACTICAL  DETAILS  OF  VACCINATION  101 

Similarly,  the  equation  for  No.  4  characteristic  will  be : 

(62-53^)100  =  6g,7_     ,^  =  +  2.73_ 
95 

Similarly,  the  equation  for  No.  3  characteristic  will  be : 
(124-17^)100  =  6g,7       .  x=-+23.53> 

Similarly,  the  equation  for  No.  2  characteristic  will  be : 

(249-7^x)100  =  68,7      ,,  =  +  18.16. 
o90 

Table  VI. 


CASES  MORE  THAN  ONCE  RE-VACCINATED  AT  SOUTHAMPTON  ROW, 
1884  TO  1885,  REGISTERED  BY  MR.  LAPIDGE. 


Characteristic  numbers. 

Number  of  cases. 

Range  of  intervals. 

Aggregate  interval. 

Average  interval. 

Hypothetical  interval. 

Calculated  nvimber  of 
exceptional  cases. 

Percentage  of  excep- 
tional cases  to  numbers 
in  Column  2. 

Number  to  be  added  or 
subtracted  from  the  calcu- 
lated numbers  in  Column  7 

to  make  the  percentage 
equal  in  Column  8. 

Percentage  of  numbers 
in  Column  9  to  those  in 
Column  2. 

6 
5 
4 
3 
2 
1 
0 

2 
10 
17 
61 
88 
134 
21 

3  to  7 
3  to  36 
3  to  30 
1  to  33 
16-30 
•08  to  15 
•02  to  23 

10 
121 

185 
690 
951-41 
1086-6 
123-27 

5 
121 

10-  82 

11-  32 
10-81 

811 
5-87 

24 
22 
20 
18 
16 
14 
12 

2 

6-14 
10-97 
33-63 
45-07 
97-10 
21 

100 
61-4 
64-53 
55-13 
51-22 
72-46 

100- 

-•70 
+  •344 
+  -0528 
+  5-92 
+  11-99 
- 10-21 
-7'38 

-35-16 
+  3-44 
+  •31 
+  9-7 

+  13-62 
-7'62 

-3514 

333 

•02  to  36 

3167-28 

9-51 

215*91 

64-84 

0 

0  1 

? 

70 

•02  to  25 

612 

8-74 

Mean 
taken. 

18 

53-39 

76-27 

-8 

-11-43 

403 

•02  to  36 

3779-28 

9-37 

18 

286*46 

71*08 

0 

0 

Cols.  1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

102       THEORY  AND  PRACTICE  OF  VACCINATION 

Table  VII. 


CASES  MORE  THAN  ONCE  RE-VACCINATED  AT  LAMB'S  CONDUIT 
STREET,  1882  TO  MARCH,  1895,  REGISTERED  BY  MR.  ADAMS. 


Characteristic  number. 

Number  of  cases. 

Range  of  intervals. 

Aggregate  interval. 

Average  interval. 

3 
> 

u 

44 

a 
"3 

o 

o 
P< 

w 

24 
22 

90 

18 
16 
14 

12 

Calculated  number  of 
exceptional  cases. 

Percentage  of  excep- 
tional cases  to  number 
in  Column  2. 

Number  to  be  added  or 
subtracted  from  the  calcu- 
lated numbers  in  Column  7 
to  make  the  percentages 
in  Column  8  equal  (58 '59. 

05  fl 

2  ® 
Si 

a  <** 
CS  fi 
°c.  S 

IP 

o  rs 

2o 
Pi  .5 

- 14-08 
+  5-35 

"T  O  OO 

+  10-33 
+  2-68 
-11-71 
-31-37 

6 
5 
4 
3 
2 
1 
0 

3 
23 
78 
154 
302 
204 
16 

6  to  12 
2  to  23 
•04  to  28 
•02  to  30 
•04  to  30 
•08  to  24 
•25  to  22 

255 
262 
814 

1639-52 
2688-49 
1419-88 
83-75 

8-5 
11-39 
10-44 
10-65 
8-90 
6-96 
5-23 

2-48 
14-55 
50-51 
88-68 
199-03 
163-81 
1599 

82-6 

63-  26 

64-  76 
57-61 

65-  9 
80-30 
99-94 

-•42 
+  1-23 
+  2-99 

+  16-91 
+  811 

-  23-89 
-502 

Total 

780 

•02  to  30 

6932-64 

8-88 

556-64 

71-36 

? 

186 

•01  to  33 

1769-88 

9-52 

Mean 
taken. 
18 

123-58 

66  44 

+  10-99 

+  5-91 

Total 

966 

•01  to  33 

8702-52 

901 

18 

758-58 

78-53 

Cols.  1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

Table  VIII. 


Charac- 
teristic 
number. 

Numbers  to  be 
added  or  subtracted 

from  Column  7, 
Table  III.,  to  make 

the  percentages 
in  Column  8, 

Table  III.,  equal. 

Numbers  to  be 
added  or  subtracted 

from  Column  7, 
Table  IV.,  to  make 

the  percentages 
in  Column  8, 

Table  IV.,  equal. 

Percentage  of 
characteristic 

number  to 
total  number 
of  cases. 

Percentage  of 
characteristic 

number  to 
total  number 
of  cases. 

Lapidge. 

Adams. 

Lapidge. 

Adams. 

6 

-35-16 

-14-08 

•6 

•38 

5 

+  3-44 

+  5-35 

3-00 

2-95 

4 

+  •31 

+  3-83 

5-10 

10- 

3 

+  9-7 

+  10-33 

18-32 

19-74 

2 

+  13-62 

+  2-68 

26-42 

38-72 

1 

-7-62 

-11-71 

40-24 

26-15 

0 

-35-14 

-31-37 

6-31 

2-05 

THE  PRACTICAL  DETAILS  OF  VACCINATION  103 


Similarly,  the  equation  for  No.  1  characteristic  will  be : 
(264-71±,)100  =  68.7_     .,,  =  _32... 

COO 

Lastly,  the  equation  for  0  characteristic  will  be : 
(36-97^)100  =  68,7.    ,.,  =  -11-55. 

The  different  values  found  for  x — and  these  represent  the 
numbers  that  have  to  be  added  or  subtracted  from  the 
number  in  column  la  to  make  the  percentages  in  column 
8a  all  equal — are  given  in  column  10. 

In  column  11  the  percentage  of  the  numbers  in  column  10 
to  the  number  of  cases  contained  in  column  2a  is  given. 

In  column  12  the  aggregate  age  of  all  the  cases  under 
the  several  characteristics  is  given  for  the  present  re-vacci- 
nation. 

In  column  13  the  average  age  is  given,  found,  of  course, 
by  dividing  the  aggregate  age  by  the  number  of  cases  in 
column  2a. 

In  column  14  the  difference  between  the  average  age  in 
column  13  and  the  average  interval  in  column  5a  is  given, 
and  this  must  necessarily  be  the  average  age  at  which  the 
first  re-vaccinations  took  place. 


LECTURE  VI. 


ON  THE  RELATION  OF  COW-POX,  HORSE-POX,  AND  CAMEL-POX 
TO  SMALL-POX. 

The  view  that  cow-pox  and  horse-pox  are  simply  modifica- 
tions of  human  small-pox,  and  owe,  not  only  their  origin,  but 
their  continued  existence  to  it,  is  one  which  has  commended 
itself  to  many  since  Jenner's  time,  for  it  accounts  readily 
for  most  of  what  may  be  called  the  peculiarities,  both  of 
cow-pox  and  horse-pox,  and  it  saves  us  from  many  diffi- 
culties which  meet  us  on  the  contrary  supposition,  viz.,  that 
cow-pox  is  an  independent  disease. 

A  good  instance  of  these  difficulties,  and  how  they  are 
met,  is  seen  in  Dr.  Ballard's  prize  essay  on  vaccination,* 
pp.  32,  33,  where  he,  while  admitting  that  the  cow  can  be 
inoculated  with  small-pox  virus,  and  that  the  lymph  collected 
from  the  resulting  vesicles  is  so  modified  that  it  no  longer 
produces  small-pox  but  only  cow-pox,  yet  explains  it  on  the 
hypothesis  that  they  are  independent  diseases,  by  supposing, 
on  the  one  hand,  that  the  cow  is  incapable  of  developing 
small-pox,  therefore  when  the  cow  is  inoculated  with  small- 
pox virus  it  is  cow-pox  which  is  produced ;  on  the  other 
hand,  he  supposes  that  man  is  capable  of  developing  both 
his  own  special  disease,  small-pox,  and  the  varioloid  disease 
of  the  cow.  Hence  that  cow-pox,  however  arising  in  the  cow, 
whether  by  the  direct  inoculation  of  small-pox  virus  or  by 

*  'Vaccination,  its  Value  and  Alleged  Dangers,'] a  prize  essay,  by 
Edward  Ballard,  M.D.,  1868. 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  105 


some  other  occult  manner,  remains  cow-pox  always  when 
again  transmitted  to  man. 

A  right  understanding  of  this  matter  is  one  of  great 
practical  importance,  for  if  it  be  true  that  cow-pox  is  but 
modified  small-pox,  then  no  longer  must  we  regard  the 
human  body  as  a  soil  foreign  to  the  vaccine  virus,  but 
rather  the  cow's,  and  thus  a  weighty  argument  now  used 
in  favour  of  animal  vaccination  would  have  to  be  transferred 
to  the  opposite  balance.  One  instance  may  be  given  of 
how  the  view  that  vaccinia  is  an  independent  disease 
operates.  Dr.  Ballard,  in  the  work  already  referred  to, 
on  p.  241,  speaking  of  the  care  to  be  taken  in  selecting 
cases  for  vaccination,  says  :  ■  He  (the  vaccinator)  should 
remember  that  the  vaccine  disease  is  one  which  is  not 
natural  to  man,  that  it  is  planted  on  a  soil  to  which  it  is 
foreign,  and  that  it  requires  constant  watchfulness  and 
judicious  cultivation  to  restrain  its  inherent  disposition  to 
deteriorate.'  This  passage  clearly  shows  Dr.  Ballard's 
view  of  cow-pox,  and  helps  to  explain  his  advocacy  for 
animal  vaccination  on  p.  253. 

The  arguments  which  may  first  be  brought  forward  in 
favour  of  the  view  of  the  direct  relation  between  cow-pox 
and  small-pox  are  those  derived  from  the  special  charac- 
teristics of  cow-pox  in  the  cow  when  compared  with  small- 
pox in  man.  It  is  generally  admitted  that  the  cow-pox  is 
propagated  among  the  cows  by  milking,  and  those  who  have 
paid  most  attention  to  the  subject  are  agreed  that  it  is  never 
transmitted  from  one  animal  to  another  except  by  direct  con- 
tact. The  disease  is  never,  like  small-pox,  conveyed  by  ex- 
halations, i.e.,  through  the  medium  of  the  atmosphere.  Thus 
it  is  only  milch  coivs  that  suffer  during  epidemics.  Jenner 
was  convinced  of  this.  On  p.  86  of  his  '  Inquiry  into  the 
Causes  and  Effects  of  Variola  Vaccinia,'  published  in  1801, 
he  writes  :  '  It  has  been  conceived  to  be  contagious  among 
cows  without  contact,  but  this  idea  cannot  be  well  founded, 
because  the  cattle  in  one  meadow  do  not  infect  those  in 
another — although  there  may  be  no  other  partition  than  a 


io6       THEORY  AND  PRACTICE  OF  VACCINATION 


hedge — unless  they  be  handled  or  milked  by  those  who 
bring  the  infectious  matter  with  them  ;  and,  of  course,  the 
smallest  particle  imaginable,  when  applied  to  a  part 
susceptible  of  its  influence,  may  produce  this  effect.'  Ceely, 
also,  in  his  '  Observations  on  the  Variola  Vaccinias,'  published 
in  1840,  from  the  Transactions  of  the  Provincial  Medical  and 
Surgical  Association,  writes  :  '  It  is  considered  that  the 
disease  is  peculiar  to  the  milch  cow,  that  it  occurs  primarily 
when  the  animal  is  in  that  condition,  and  that  it  is  casually 
propagated  to  others  by  the  hands  of  the  milkers.  ...  I 
have  frequently  witnessed  the  fact  that  sturks,  dry  heifers, 
dry  cows,  and  milch  cows  milked  by  other  hands,  grazing 
in  the  same  pastures,  feeding  in  the  same  sheds,  and  in 
contiguous  stalls,  remain  exempt  from  the  disease.' 

Both  the  above  observers,  then,  agree  in  thinking  the 
disease  is  seldom,  if  ever,  conveyed  from  one  animal  to 
another  except  by  direct  contact. 

Another  fact  may  be  mentioned  here,  showing,  as  far  as 
it  goes,  the  same  thing.  During  the  practice  of  animal 
vaccination  there  is  not,  as  far  as  is  known,  a  single 
instance  on  record  of  one  animal  becoming  affected  from 
another  except  by  direct  inoculation.  There  certainly  has 
not  been  one  at  the  Animal  Lymph  Establishment  at 
Lamb's  Conduit  Street  since  it  was  opened  in  1882,  and 
during  this  time,  up  to  July,  1895,  there  have  been  upward 
of  3,300  calves  vaccinated  there,  and  not  one  of  them  has 
been  affected  except  by  direct  vaccination.  Now,  since  in 
animal  vaccination  the  true  cow-pox,  unmodified  by  trans- 
mission through  man,  is  conveyed,  this  fact  is  of  some  sig- 
nificance. 

It  will  scarcely  be  necessary  to  consider  further  evidence 
on  this  point,  as  no  observations  tend  to  the  contrary  con- 
clusion, except  some  experiments  made  in  India  in  1832,  of 
which  notice  will  be  taken  further  on. 

How,  then,  does  the  disease  arise  ?  Jenner  suggests  its 
origin  from  the  sore  heels  of  horses,  and  no  one  reading 
his  work  will  think  that  he  arrived  at  this  conclusion  with- 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  107 


out  due  observation.  This  opinion  of  his,  it  is  true,  is 
no  longer  entertained,  partially  because  the  variolous  affec- 
tion of  the  heels  has  been  ignorantly  confounded  with  the 
grease,  and  partially  because  the  explanation  does  not 
account  for  the  origin  of  all  cases  of  cow-pox ;  but  that 
this  is  the  way  in  which  the  disease  has  occasionally  been 
communicated  to  the  cow  seems  more  than  probable. 

Other  observers,  such  as  Ceely,  offer  no  explanation  of 
the  origin  of  cow-pox.  Before  reflecting  further  upon  the 
above  peculiarity  of  cow-pox,  it  will  be  convenient  to  con- 
sider another,  and  that  is,  its  localization  to  the  udder  and 
teats.  All  observers  are  agreed  upon  this  point.  The 
disease  is  conveyed  by  the  milkers  to  the  udder  and  teats, 
on  which  vesicles  are  formed,  but  the  vesicles  appear  on  no 
other  part  of  the  body.  For  the  conveyance  of  the  disease, 
it  is  known  that  the  healthy  hand  is  quite  as  efficacious  as 
when  it  is  itself  affected. 

Horse-pox  seems  also  to  have  both  the  above-mentioned 
peculiarities  of  cow-pox,  the  only  difference  being  that  in 
the  horse  the  disease  is  localized  at  the  heels  instead  of  at 
the  udders.  Horses,  however,  often  inoculate  the  mouth 
and  the  mucous  membrane  of  the  nose  by  biting  their 
already  affected  and  itching  heels.*  The  mouths  of  the 
horses  are  always  affected  subsequently  to  their  heels. 

Horses  suffer  quite  as  much  as  mares  do  from  the  disease, 
whereas  in  cow-pox  the  milch  cows  alone  are  affected. 

It  is  stated  that  in  Asia,  in  the  province  of  Lus,  the 
milkers  have  a  disease  long  known  as  photo-shooter,  con- 
tracted from  milking  the  camel  in  the  same  way  as  cow- 
pox  is  contracted  in  milking  the  cow,  and  that  it  has  been 
found  to  be  equally  protective  against  the  small- pox. t 
Now,  it  is  very  remarkable  that  the  cow  and  horse  and 
camel  should  each  be  liable  to  a  disease  (producing  vesicles 
so  like  those  of  small-pox,  and  that  the  lymph  from  them, 

*  Seaton's  '  Handbook  of  Vaccination,'  p.  27. 

t  Article,  by  A.  W.,  in  Once  a  Week,  July  4,  1863,  p.  36. 


108       THEORY  AND  PRACTICE  OF  VACCINATION 

when  used  on  man,  protects  him  from  small-pox)  on  those 
parts  of  their  bodies  which  are  brought  into  contact  with 
the  hand  of  man.  It  thus  seems  likely  that  if  cows  and 
camels  were  not  milked,  and  horses  were  not  shod,  their 
respective  varioloid  diseases  would  cease,  as  far  as  we  can 
see,  to  exist.  Moreover,  the  parts  of  the  respective  animals 
which  are  affected  are  those  very  parts  which  are  chiefly 
handled  frequently  by  man.  In  order  to  account  for  the 
continuance  of  the  disease,  it  seems  necessary  to  suppose 
that  it  is  a  derivative  from  small-pox,  and,  consequently, 
that  if  small-pox  became  extinct,  cow-pox,  horse-pox  and 
camel-pox  would  cease  to  exist.  This  supposition  obtains 
much  support  when  we  find  that  cow-pox  has  become  much 
less  prevalent ;  and  this  is  remarkable,  for  we  should  have 
expected  that  with  the  general  distribution  of  cow-pox  virus 
over  the  land  for  the  purposes  of  vaccination,  cow-pox,  if  a 
disease  per  se,  would  have  increased  rather  than  diminished. 
That  cow-pox  does  prevail  chiefly  during  great  epidemics  of 
small-pox,  and  that  it  is  more  rare  now  than  formerly,  are 
facts  generally  admitted  ;  however,  the  following  reason  for 
thinking  so  may  be  given. 

From  1838  to  1841,  cow-pox  seems  to  have  again  been 
frequent  in  England.  It  was  during  these  years  that  most 
of  the  new  stocks  of  vaccine  lymph  arose.  Mr.  Estlin  met 
with  the  disease  in  Gloucestershire  and  raised  a  fresh  stock 
of  vaccine  lymph.  Mr.  Fox  and  Mr.  Sweeting  also  met  with 
the  disease  in  Dorsetshire,  and  raised  lymph  stocks. 

Dr.  Seaton,  in  his  ' Handbook  of  Vaccination,'  p.  414, 
remarks  concerning  this  :  '  It  is  certainly  very  singular  that 
it  (cow-pox)  should  have  been  seen  by  so  many  observers 
about  the  time,  and  it  deserves  particular  notice  that  this 
was  at  a  period  when  one  of  the  most  formidable  epidemics 
of  small-pox  that  has  occurred  in  the  present  century  was 
sweeping  over  the  land.' 

On  reading  Jenner's  treatise  '  An  Inquiry  into  the  Causes 
and  Effects  of  the  Variolse  Vacciniae,'  one  is  at  once  struck 
with  the  frequent  occurrence  of  the  disease  in  Jenner's 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  109 


immediate  neighbourhood,  viz.,  Berkeley  in  Gloucestershire. 
He  mentions  it  incidentally  as  occurring 


In  1759  on  page  47  ... 

...    2,596  deaths  from  small-pox  in  London 

„  1760 

13... 

...  2,187 

,,  1765 

11... 

...  2,498 

>) 

„  1770 

9... 

...  1,986 

)j 

„  1780 

20... 

871 

»» 

„  1782 

„  22,  23  ... 

636 

»» 

„  1791 

21... 

...  1,747 

?> 

„  1794 

„  21... 

...  1,913 

>> 

„  1796 

„  15,  16  ... 

...  3,548 

„  1798 

47... 

...  2,237 

Besides  these  incidental  references,  we  have  this  notable 
passage  on  page  47,  from  which  we  may  infer  that  cow-pox 
was  then  almost  of  yearly  occurrence.  Having  broken  off 
his  observations  on  the  disease  in  1796,  he  writes  in  1801  : 
'  The  spring  of  the  year  1797,  which  I  intended  particularly 
to  have  devoted  to  the  completion  of  this  investigation, 
proved,  from  its  dryness,  remarkably  adverse  to  my  wishes  ' 
(this  year  1797,  it  may  be  permitted  to  remark,  was  one 
remarkably  free  from  small-pox  in  London  :  there  were 
only  522  deaths  in  the  year,  and  there  had  not  been  so  few 
deaths  since  the  year  1702,  i.e.,  for  a  period  of  ninety-seven 
years)  ;  '  for  it  frequently  happens  while  the  farmers'  horses 
are  exposed  to  the  cold  rains  which  fall  at  this  season,  that 
their  heels  become  diseased,  and  no  cow-pox  then  appeared 
in  the  neighbourhood.'  The  disease,  however,  did  appear 
the  following  year,  viz.,  in  1798,  a  year  in  which  small-pox 
in  London  was  prevalent,  there  being  2,237  deaths. 

Nobody  at  the  present  time  would  confidently  look  forward 
to  the  return  of  cow-pox  in  order  to  complete  observations 
commenced  the  previous  year.  Concerning  the  rarity  of  the 
disease  in  1840,  Mr.  Ceely,  in  discussing  Dr.  Sonderland's  (of 
Bremen)  article  in  the  Medical  Gazette  *  November  9,  1831, 
says  on  page  94  of  his  work,  '  Observations  on  the  Variola 

*  See  extract  in  Medical  Gazette,  November  9,  1831,  taken  from 
Journal  des  PraMischen  Heilkunde,  January,  1831. 


no       THEORY  AND  PRACTICE  OF  VACCINATION 


Vaccinia  ' :  '  The  result  of  careful  and  extensive  inquiry 
induced  the  belief  that  the  asserted  comparative  rarity  of 
the  disease  was  true  as  regarded  this  neighbourhood.'  On 
page  47  he  says :  '  I  am  inclined  to  believe,  from  all  the 
information  I  have  been  able  to  procure,  that  cow-pox  is 
not  so  often  met  with  as  it  was  forty  or  fifty  years  ago ; 
but  upon  this  point  I  speak  with  much  hesitation.'  Mr. 
Ceely,  be  it  remembered,  was  then  writing  at  a  time  when 
cow-pox  was  more  prevalent  at  Aylesbury  than  it  had  been 
for  some  years  past,  and  than  it  has  been  since. 

Horse-pox  also  seems  liable  to  prevail  during  epidemics  of 
small-pox.  In  the  account  of  the  disease  at  Eieumes  in 
1860,  it  is  expressly  stated  that  human  small-pox  was  very 
prevalent  at  the  time.    (See  Ballard  Prize  Essay,  p.  32.) 

Now,  it  appears  likely,  since  small-pox  and  cow-pox  are 
so  similar — if  not  directly  related — that  the  same  conditions 
existing  at  certain  times  would  be  favourable  to  the  spread 
of  both  diseases,  and  this  might  be  given  as  a  reason  for 
the  prevalence  of  the  two  together  ;  but  against  this  we 
may  reasonably  suppose  that  if  it  had  not  been  for  vaccina- 
tion, epidemics  of  small-pox  would  have  been  more  widely 
spread  than  they  have  been  during  this  century  (see  Dr. 
Ballard's  Prize  Essay,  p.  71  et  seq.).  But  where,  then,  are 
the  corresponding  epidemics  of  cow-pox,  which  should  have 
occurred  if  cow-pox  be  an  independent  disease  ?  They  also, 
together  with  the  small-pox  epidemics,  have  decreased.  It 
has  been  urged  that  the  milkers  are  now  all  vaccinated,  and 
therefore  are  less  likely  to  become  affected  with  the  natural 
disease,  and  therefore  do  not  so  readily  convey  the  disease ; 
but  this  cannot  be  the  explanation,  for  the  healthy  hand 
seems  to  convey  the  disease  from  one  animal  to  another 
quite  as  readily  as  the  affected  hand ;  besides,  the  disease 
must  incapacitate  those  suffering  from  it  from  doing  their 
work  as  milkers — at  all  events,  for  some  time  during  its 
progress.  This,  however,  is  beyond  the  point,  for  it  is  not 
contended  that  the  disease  spreads  less  on  a  farm  now  than 
formerly,  but  that  for  years  together  it  does  not  exist  at  all. 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  in 


But  besides  the  indirect  evidence  given  above,  there  is 
positive  evidence  to  bring  forward  to  show  that  small-pox 
may  be  communicated  by  inoculation  to  horned  cattle,  and 
that  the  resulting  vesicles  yield  lymph  having  all  the 
properties  of  vaccine  lymph.  In  other  words,  small-pox,  by 
one  transmission  through  an  animal,  becomes  modified,  so 
that  it  is  not  only  no  longer  infectious,  but  also  is  limited 
as  regards  the  eruption  to  the  points  of  inoculation. 

This,  indeed,  is  not  a  unique  experience  in  pathology, 
for  in  anthrax  we  have  an  analogous  example.  Anthrax,  as 
is  well  known,  is  a  very  fatal  and  infectious  disease  among 
horned  cattle.  If  a  mouse  is  inoculated  with  the  disease, 
as  it  may  readily  be,  it  dies  ;  but  if  a  healthy  animal  such 
as  a  sheep  or  ox  be  inoculated  from  the  mouse,  it  produces 
a  local  sore  on  the  sheep  or  ox  which  does  not  prove  fatal, 
and  subsequently  protects  it  from  the  virulent  form  of  the 
disease.  Here  the  mouse  in  anthrax  takes  the  place  of  the 
cow  in  small-pox.  In  both  cases  the  virus  is  altered :  from 
being  virulent,  it  becomes  benign. 

Dr.  Gassner,*  of  Gunzburg,  so  early  as  1801,  succeeded 
in  inoculating  a  cow  on  the  eleventh  experiment  with  the 
small-pox  virus,  and  used  the  lymph  thus  obtained  for 
vaccinating  four  children,  and  from  them  seventeen  others. 
No  small-pox  appeared  among  these  children.  In  1836, 
and  again  in  1838,  Dr.  Theile,  of  Kasan,  succeeded  in 
inoculating  the  cow  with  small-pox  matter,  and  he  used  the 
lymph  for  the  vaccination  of  children.  He  thus  states  his 
conclusions  on  this  point : 

'  1st.  The  so-called  vaccine  is  not  an  eruptive  disease 
peculiar  to  the  cow,  but  is  produced  in  it  by  the  transmis- 
sion of  human  small-pox  to  it ;  and  the  man,  and  not  the 
cow,  as  has  hitherto  been  thought,  is  the  source  of  the 
disease. 

'  2nd.  The  mild  disease  thus  caused  in  the  cow  can,  by 
direct  transmission  from  the  cowr  to  man,  produce  in  him 

*  Heine  in  Henke's  Zeitschr.  Erganzungsclirift,  xxx,,  p.  57 ;  also 
British  and  Foreign  Medical  Beview,  January,  1840. 


ii2       THEORY  AND  PRACTICE  OF  VACCINATION 

as  mild  a  disease,  which  gives  protection  against  the  natural 
small-pox.' 

His  other  conclusions  refer  to  an  artificial  method  of  pro- 
ducing this  modification  in  small-pox  virus  without  the  aid 
of  the  cow.  This  he  thought  he  did  by  preserving  small- 
pox virus  for  ten  days  between  two  pieces  of  glass,  and 
then  diluting  it  with  milk,  and  using  this  mixture  for 
vaccinating  children.  The  lymph  obtained  from  the 
resulting  vesicles  he  again  kept,  and  diluted  with  milk  as 
before.  After  ten  generations  the  lymph  had  become 
modified,  and  could  be  used  without  the  addition  of  milk.* 
Mr.  Ceely,  in  18B9,  also  succeeded  in  inoculating  cows  with 
small-pox,  and  found  that  the  resulting  lymph  caused  a 
disease  identical  with  vaccinia.  His  experiments  were  pub- 
lished in  the  eighth  volume  of  the  Transactions  of  the 
Provincial  Medical  and  Surgical  Associations,  and  also  in 
a  separate  work,  entitled  '  Observations  on  the  Variola 
Vaccinia,'  1840,  Worcester.  In  a  note,  on  p.  140  of  the 
latter,  which  is  quoted  to  show  that  his  experiments  were 
independent  of  Dr.  Theile's,  he  says  :  "  But  I  am  gratified 
to  learn  that  since  the  announcement  of  those  [experi- 
ments] which  I  have  just  detailed,  intelligence  has  been 
received  of  the  success  of  Dr.  Basil  Theile,  of  Kasan,  in 
Bussia,  in  similar  experiments.' 

He  also,  on  the  same  page,  states  that  when  he  wrote 
more  than  2,000  subjects  had  been  vaccinated  with  his 
variola  vaccine  lymph.  About  this  time  also  Dr.  Beiter,  of 
Munich,  succeeded.  He  had  failed  previously,  but  having 
adopted  the  method  of  inoculation  practised  by  Dr.  Theile, 
he  succeeded. 

In  1840,  Mr.  Badcock,  then  a  chemist  in  Brighton, 
succeeded  on  his  first  attempt,  and  afterwards  succeeded 
some  thirty  or  forty  times  ;  nevertheless,  his  success  only 
amounted  to  about  7  per  cent,  of  his  trials.!    Some  of  the 

*  Henke's  Zeitschrift  fur  die  Staatsarzneikund,  1839. 
•j-  '  Details  of  Experiments  Proving  the  Identity  of  Cow-pox  and 
Small-pox,'  Brighton,  1845. 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  113 


lymph  thus  obtained  by  Mr.  Badcock  furnished  the  stock 
which  was  used  at  the  Highgate  Small-pox  and  Vaccination 
Hospital  for  some  fifteen  years  or  more  by  Mr.  Mar  son. 

Dr.  Vy,*  of  Elburg,  in  1867,  also  succeeded,  and  used  the 
lymph  for  vaccination.  Most,  if  not  all,  experimenters  who 
have  succeeded  agree  that  there  is  considerable  difficulty  in 
obtaining  a  characteristic  pock  on  the  cow  from  inoculation 
of  small-pox  ;  and,  indeed,  there  are  not  a  few  who  have 
entirely  failed. 

Mr.  Marson  tried  forty  times  in  succession  without 
result.  Coleman,  King,  Dalton,  Sacco,  Fiard,  and  Bous- 
quet  all  failed;  but  M.  Chauveau,  and  associated  with 
him  MM.  Yiennois  and  Meynet,  who  called  papular  tume- 
faction a  success,  succeeded  every  time,  and  from  these 
papules  they  produced  small-pox.  Small-pox  is  also  said 
to  have  resulted  from  experiments  similar  to  those  of 
M.  Chauveau  at  Boston,  U.S.,  and  also  at  the  Veterinary 
School  of  Berlin.f 

In  these  experiments,  however,  there  is  no  evidence  to 
show  that  the  original  small-pox  virus,  with  which  the 
scratches  were  deluged,  may  not  have  been  taken  up  again 
and  used  unchanged  for  the  inoculation  rather  than  the 
vaccination  of  children. 

On  November  18,  1885,  Dr.  Simpson,  then  of  Aberdeen, 
sent  me  fifteen  charge  points  to  Lamb's  Conduit  Street, 
with  the  following  history  : 

He  had  obtained  some  small-pox  lymph  from  an  un- 
vaccinated  female,  F.  P.,  aged  13,  (a)  on  the  fifth  day  of 
eruption,  and  (b)  on  the  sixth  day  of  eruption.  On  the 
eleventh  he  inoculated  a  cow  with  the  small-pox  lymph  on 
one  teat  with  one  scarification  from  the  lymph  which  had 
been  taken  on  the  fifth  day  of  the  girl's  eruption,  and  on 
another  teat  with  two  scarifications  from  lymph  of  the  sixth 
day  of  eruption. 

*  Bulletin  de  V Acad,  de  Med.,  t.  xxxi.,  p.  430. 
f  See  Seaton's  '  Handbook  of  Vaccination,'  p.  55. 


ii4       THEORY  AND  PRACTICE  OF  VACCINATION 


On  November  17,  the  seventh  day  afterwards,  the  single 
scarification  yielded  the  fifteen  points  which  were  sent  to 
Lamb's  Conduit  Street. 

The  two  scarifications  done  with  the  sixth-day  small-pox 
lymph  only  became  papular. 

The  lymph  on  the  fifteen  points  was  used  at  Lamb's 
Conduit  Street  on  November  21,  1885,  for  the  inoculation 
of  a  male  calf  (938),  aged  about  6  months,  in  five  incisions, 
three  of  which  had  taken,  and  were  vesicular  on  November  26. 
From  this  calf,  whose  vaccine  vesicles  so  exactly  resembled 
the  current  vesicles,  a  child  and  another  calf  (941)  were 
vaccinated,  the  child  in  five  places,  the  calf  in  seventeen. 
The  child  was  kept  under  observation,  and  it  went  through 
a  course  of  normal  vaccinia.  No  eruption  occurred,  and  no 
small-pox  was  communicated  to  others.  Calf  941  was 
successful  in  six  out  of  the  seventeen  places  it  had  been 
vaccinated  in,  and  lymph  was  taken  on  December  1,  i.e., 
120  hours  after  vaccination,  for  the  vaccination  of  another 
child  and  another  calf  (994).  The  child  was  vaccinated  by 
five  separate  insertions  of  the  lymph,  all  of  which  were  suc- 
cessful. This  child  also  was  kept  under  observation,  and  it 
went  through  a  perfectly  normal  course  of  vaccination,  and 
no  small-pox  was  communicated  to  others.  On  December  5, 
ninety-six  hours  afterwards,  two  other  calves  were  vaccinated 
from  994,  and  from  this  date  to  May  6,  1886,  Simpson's 
lymph  was  regularly  used  at  Lamb's  Conduit  Street,  concur- 
rently with  the  Bordeaux  lymph,  which  was  that  ordinarily- 
used  at  the  station.  During  this  time  1,247  children  were 
vaccinated  with  it  and  seventy-nine  calves.  After  the  use  of 
Simpson's  lymph,  out  of  the  1,247  children  vaccinated  with 
it,  fifteen  were  brought  back  with  some  abnormality,  or 
1*2  per  cent. ;  and  after  the  use  of  the  Bordeaux  lymph, 
which  was  used  concurrently  with  Simpson's,  there  were 
eight  out  of  685  children  vaccinated  with  it  brought  back  to 
the  station  for  a  like  cause,  or  1*16  per  cent. 

The  writer's  insertion  success  out  of  1,174  cases  was  98*4 
per  cent,  with  Simpson's,  and  with  Bordeaux,  out  of  678- 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  115 

cases,  it  was  98*2  per  cent.  Simpson's  lymph  thus  seemed 
a  trifle  more  active  than  the  Bordeaux. 

No  case  of  small-pox  was  heard  of  among  the  children, 
and  no  case  of  communication  of  small-pox  to  others. 

The  following  synopsis  of  the  origin  and  descent  of 
Simpson's  lymph  may  prove  useful : 


Date. 

Synopsis  of  the  Origin  of  Simpson's  Lymph. 

1885. 
Nov.  10  | 
„  ID 

»;  11 

Small-pox  virus  obtained  from  F.  P.,  a  female,  aged  13. 
1 

Cow  inoculated. 

H  17 

1 

15  points  charge  from  the  cow  vaccinated  on  the  17th  sent 
to  Lamb's  Conduit  Street,  from  Aberdeen. 

„  21 

1 

Calf  938,  aged  6  months,  vaccinated. 
1 

„  26 

1  1 
Child.             Calf  941. 

1 

Dec.  1 

1  1 
Child.             Calf  994. 

„  5 

1  1 
Calf  948.          Calf  947. 

From  this  date  to  May  6,  1886,  Simpson's  lymph  was  used 
regularly  at  Lamb's  Conduit  Street. 

Lastly,  the  writer  was  associated  with  Dr.  Klein,  whose 
paper  on  the  subject  is  published  in  the  Supplement  con- 
taining the  Eeport  of  the  Medical  Officer  of  the  Twenty- 
second  Annual  Eeport  of  the  Local  Government  Board  for 
1892-93,  in  which  photographs  are  reproduced,  showing 
the  vaccinated  arms  of  the  children.  The  following  is  a 
synopsis  of  a  portion  of  his  report : 


8—2 


Ii6       THEORY  AND  PRACTICE  OF  VACCINATION 


Synopsis  of  Dr.  Klein's  Report. 


Date. 

Synopsis  of  the  Origin  of  Klein's  Lymph. 

1892. 
May  31 

„  31 

Collected  small-pox  lymph*  from  (a)  L.  L.,  aged  13,  unvac- 
cinated,  whose  initial  illness  was  on  May  23,*^and  had 
confluent  small-pox  May  25. 

(b)  E.  L.,  aged  32,  vaccinated  in  infancy,  initial  illness 
May  20,  confluent  small-pox  May  24.  This  lymph  (from 
both  cases)  was  inoculated  at  the  Brown  Institution  into 

„  31 

Calf  2. 

June  4 

1 

Calf  4. 

q 

• 

6,  transferred  to  Lamb's  Conduit  Street. 

„  13 

i 

8,  young  bull. 

July  14 

| 

Scab  from  infant  (L.). 

„  15 

1 

Calf  16,  t37pical  vaccinia. 

„  20 

i 

Points. 

1 

„  20 

1  1 
Infant  (L.  S.),  female.          Infant  (F.  M.  B.),  female. 

The  three  children  who  were  vaccinated  from  this  lymph 
series  were  closely  watched,  but  the  vaccination  was  perfectly 
normal. 

It  has  been  mentioned  that  the  inoculation  of  small-pox 
on  animals  is  a  difficult  matter,  and  only  a  few  succeed. 
Such,  however,  is  not  the  case  when  animals  are  vaccinated 
with  current,  i.e.,  humanized  lymph.  This  fact  requires 
some  consideration,  because  it  can  be  urged  in  support  of 
the  view  that  small-pox  and  cow-pox  are  distinct  diseases. 
We  have  seen  that  this  difficulty  is  only  in  the  transference 
of  small-pox  to  the  animal,  and  the  probable  reason  is  this, 
that  the  small-pox  lymph  is  taken  always  from  the  general 
eruption  of  small-pox.  To  make  it  similar  to  vaccination 
the  lymph  should  be  taken  on  the  eighth  day  from  the  mother 

*  The  lymph  was  collected  at  the  hospital  ship. 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  117 

vesicle  of  an  inoculated  human  individual ;  but  the  law  does 
not  allow  this  in  England. 

Some  have  held  that  the  cow-pox  is  sometimes  infectious 
among  horned  cattle.  Baron,  in  his  '  Life  of  Jenner,'  p.  234, 
says,  '  I  think  there  is  good  ground  for  believing  that  the 
disease  as  originally  noted  by  Dr.  Jenner  was  the  epidemic  or 
local  remains  of  the  more  general  or  epizootic  disease  which 
prevailed  in  many  parts  of  this  island  at  the  period  when 
Dr.  Layard  wrote.' 

He  here  refers  to  the  epidemic  described  by  Dr.  Layard,* 
which  occurred  in  1745  to  1756,  and  again  from  1760  to 
1770.  This  epidemic  Dr.  Layard  considered  to  be  of  the 
variolous  kind.  He  says  :  '  It  bears  all  the  characteristics, 
symptoms,  crises,  and  events  of  the  small-pox,  and,  whether 
received  by  contagion  or  by  inoculation,  has  the  same 
appearances,  stages,  and  determinations.'  Yet  his  subse- 
quent description  of  the  disease  is  not  altogether  consistent 
with  this  statement.  This  opinion  of  the  nature  of  the 
epidemic  continued  until  1865,  in  which  year  the  cattle- 
plague  made  its  appearance  in  England.  It  was  soon 
recognised  to  be  identical  with  the  disease  described  by 
Layard,  and  its  likeness  to  small-pox  was  again  insisted 
upon  by  several,  among  whom  was  Dr.  Murchison. 

In  the  report  of  Dr.  Murchison  to  the  Privy  Council,  he 
gives  this  likeness  as  a  reason  to  try  the  effect  of  vaccination 
on  the  disease ;  and  again,  writing  to  the  Times  after  this 
had  been  tried  and  found  of  no  avail,  he  says  :  '  The  points 
of  resemblance  between  cattle-plague  and  small-pox  are  so 
striking,  that  certain  observers  were  led  to  hope  that 
vaccination  might  protect,'  etc.t  The  above  quotation  is 
sufficient  to  show  that  the  cattle-plague  did  bear  some 
resemblance  to  small-pox,  but  the  following  established 
points  of  difference  will  prove  that  they  are  not  identical 
diseases,  and  are  not  any  more  related  than  scarlet  fever  is 
to  measles  : 

*  Philosophical  Transactions  for  the  year  1780. 

f  Letter  of  Dr.  Murchison  to  the  Times,  January  30,  1866. 


1 1 8       THEORY  AND  PRACTICE  OF  VACCINATION 


1st.  The  amount  of  the  eruption  in  cattle-plague  bears 
no  relation  to  its  fatality,  which  is  certainly  the  case  in  the 
great  majority  of  the  cases  of  small-pox. 

2nd.  The  eruption  in  the  two  diseases  is  anatomically 
different. 

3rd.  When  cattle-plague  is  conveyed  by  inoculation  from 
one  animal  to  another  there  is  no  local  development  at  the 
seat  of  inoculation,  as  occurs  when  small-pox  is  inoculated. 

4th.  Vaccination  has  been  found  to  afford  no  protection 
against  cattle-plague. 

The  epidemics  of  1745  and  1760  must  not  any  longer  be 
regarded  in  any  way  as  the  small-pox  among  horned  cattle. 

The  disease  in  India  known  as  bussunt,  mhata,  or  gotee,* 
is  thus  described  by  Mr.  Lamb  :  '  The  animals  which  were 
at  first  affected  had  been  for  a  day  or  two  previously  dull 
and  stupid.  They  were  afterwards  seized  with  cough,  and 
much  phlegm  collected  in  their  mouths  and  fauces.  The 
animals  had  at  this  time  no  inclination  for  food.  There  is 
a  discharge  of  saliva  from  the  mouth,  then  follow  universal 
tremor  and  great  heat  of  the  head,  chest,  and  body,  as  far 
back  as  the  loins,  while  the  hindquarters  are  cold.  The 
whole  body  then  becomes  hot,  and  the  animals  suffer  from 
intense  thirst.  The  mouth  and  fauces  appear  to  be  the 
principal  seat  of  the  disease,  being  in  some  instances  one 
mass  of  ulceration.  On  the  fifth  day  the  eruption  appears 
about  the  udder,  sometimes  only  a  few  pustules,  and  at 
other  times  they  are  numerous  and  confluent ;  but  the 
result  of  the  attack  does  not  appear  to  depend  much  on  the 
eruption.  Whether  the  pustules  are  numerous  or  rare, 
the  disease  is  nearly  always  fatal,  and  unless  measures  are 
taken  to  separate  the  diseased  from  the  healthy,  it  speedily 
runs  throughout  the  whole  herd,  sparing  few. 

'  In  those  who  do  escape  after  taking  the  infection  the 
favourable  symptom  is  a  spontaneous  diarrhoea,  in  which 
the  dejections  are  large,  watery,  and  offensive.    Many  die 

*  Transactions  of  the  Medical  and  Physical  Society  of  Calcutta, 
vol.  viii. 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  119 


before  the  eruption  makes  its  appearance,  but  the  fever  is 
always  known  by  the  discharge  of  the  saliva.' 

Mr.  Macpherson,  Superintendent  of  Vaccination  at  Moor- 
shedabacl,  tried  inoculating  this  disease  on  children  in  1832, 
hoping  thereby  to  obtain  a  new  stock  of  vaccine  lymph,  and 
he  describes  his  experiments  in  the  following  words  '  All 
the  cattle  in  the  neighbourhood  became  affected,  and, 
amongst  others,  two  belonging  to  one  of  my  own  vaccinators. 
I  had  them  covered  with  blankets,  leaving  merely  the  udder 
and  teats  exposed  to  the  air.  On  the  seventh  day  two  small 
pustules  made  their  appearance  on  the  teats  of  one,  which 
died  upon  the  tenth,  and  the  crusts  were  removed  on  the 
twelfth  day.  From  these  crusts  eleven  native  children  were 
inoculated,  one  of  them  successfully.  A  vesicle  appeared 
on  the  fifth  clay,  which  continued  to  increase  till  the  ninth 
day,  when  it  had  all  the  characters  of  true  vaccine  ;  the 
child  suffered  much  from  fever  for  four  days.  Two  children 
were  vaccinated  from  this  vesicle  with  complete  success,  the 
symptomatic  fever  being  very  severe.  From  these  two 
children  five  others  were  successfully  vaccinated,  and  the 
stock  thus  established  was  afterwards  regularly  continued. 
Some  of  the  children  vaccinated  with  the  lymph  were  tested 
by  variolous  inoculation  and  exposure  to  variolous  infection 
and  found  secure.' 

Dr.  Seaton,  commenting  upon  the  above  related  experi- 
ments, very  justly  remarks  :f  '  From  these  facts  it  is  not  to 
be  doubted  that  a  case  of  cow-pox  in  the  cow  had  been  met 
with ;  but  what  is  to  be  doubted  is  that  the  gotee — the 
malignant  disease  above  referred  to  —  was  the  source  of 
infection,  for  the  eruption,  so  far  from  being  like  that 
said  to  be  prevalent,  viz.,  one  of  pustules  all  over  the 
body,  terminating  in  ulceration,  was  a  couple  of  pustules 
(vesicles)  only,  having  exactly  the  characters  of  an  ordinary 

*  Transactions  of  the  Medical  and  Plrysical  Society  of  Calcutta, 
vol.  vi.,  also  Duncan  Stewart's  '  Report  on  Small-pox,  Calcutta,'  1844, 
pp.  84  and  85. 

f  Seaton's  '  Handbook  of  Vaccination,'  p.  64. 


i2o       THEORY  AND  PRACTICE  OF  VACCINATION 


case  of  casual  cow-pox.'  Dr.  Duncan  Stewart,*  who  re- 
ports this  case,  regrets  that  information  was  not  given 
more  fully  regarding  the  appearance  of  the  disease  in 
the  cows  from  which  he  took  the  crusts,  one  of  which 
succeeded. 

In  1833  Mr.  Furnell,!  a  civil  surgeon  of  Silhat,  in  Assam, 
having  seen  a  report  of  Mr.  Macpherson's  experiments  of 
the  preceding  year,  determined  to  repeat  them.  He  com- 
menced by  vaccinating  four  children  with  the  scabs  taken 
from  the  back  of  an  animal  suffering  from  gotee,  but  with- 
out effect.  Having  shortly  afterwards  to  leave  Silhat  on 
account  of  his  health,  he  asked  Mr.  David  Brown,  then 
Assistant- Surgeon  of  the  Silhat  Light  Infantry,  to  continue 
the  experiments.  A  reward  was  offered  for  an  animal 
suffering  from  the  disease,  which  was  shortly  obtained. 
Nothing,  however,  is  said  of  the  symptoms  of  the  disease 
manifested  by  the  animal,  except  that  it  was  thin  and  out 
of  condition.  It  appears,  however,  that  it  had  a  general 
eruption,  for  scabs  were  taken  from  the  back  of  the  animal 
and  used  for  the  vaccination  of  four  children.  All  these 
vaccinations  were  successful.  The  resulting  vesicles  are 
said  to  have  run  a  natural  course,  and  from  them  four  more 
children  were  vaccinated.  Mr.  Brown's  J  words  are  as 
follows :  '  From  this  new  virus  vaccination  was  carefully 
propagated  through  successive  numbers  of  children  by 
either  Mr.  Furnell  or  myself,  or  the  native  vaccinators 
under  our  superintendence,  through  the  months  of  October 
and  November.'  On  November  23,  1833,  Major  Orchard's 
child  and  three  native  children  were  vaccinated  from  one 
child  with  this  virus,  and  on  December  1,  i.e.,  on  the  ninth 
day,  Mr.  Furnell  vaccinated  his  own  child  from  one  of  these 
native  children.  A  day  or  two  after  this,  in  due  time  Major 
Orchard's  child  had  severe  small-pox,  and  the  three  native 

*  Stewart,  op.  cit.,  p.  148. 

t  Transactions  of  the  Medical  and  Physical  Society  of  Calcutta, 
Appendix,  vol.  vii.,  p.  453,  Mr.  Furnell's  account. 
%  Op.  cit.,  vol.  viii.,  p.  97,  Mr.  Brown's  account. 


THE  RELATION  OF  COW-POX  TO  SMALL-POX  121 


children  all  had  slight  but  characteristic  eruptions.  Mr. 
Furnell's  child,  also,  a  week  after  this,  had  small-pox,  of 
which  it  died  on  December  20.  On  making  inquiries  after- 
wards, Mr.  Furnell  ascertained  that  the  native  child  from 
whom  he  had  vaccinated  Major  Orchard's  child  and  the 
three  native  children  had  had  a  general  eruption  after 
having  been  inspected.  It  could  not,  however,  be  ascer- 
tained how  many  of  the  native  children  vaccinated  during 
October  and  November  had  suffered  from  small-pox,  for  no 
register  was  kept,  and  the  children  after  vaccination  were 
not  again  seen.  Mr.  Brown,  apologizing  for  this,  says  : 
'  Why  more  children  were  not  inspected  was  owing  to  no 
register  having  been  kept.'  And  he  goes  on  to  say  :  '  In 
explanation  of  this  apparent  neglect  I  may  state  that  the 
superintendence  of  vaccination  on  Mr.  Furnell's  part  and 
my  own  was  gratuitous,  and  not  considered  at  the  time  as 
part  of  our  duties.' 

From  the  account  of  these  last  experiments  of  Mr. 
Furnell's  and  Mr.  Brown's,  it  is  not  unjustifiable  to  regard 
them  as  of  little  or  no  scientific  value : 

(1)  Because  native  vaccinators  conducted  some,  if  not 
most,  of  the  vaccinations.* 

(%)  No  description  is  given  of  the  symptoms  of  the 
animal  from  whom  the  scabs  were  taken,  save  that  it  was 
thin  and  out  of  condition,  and  incidentally  that  it  had  a 
general  eruption. 

(3)  No  register  was  kept,  Mr.  Brown  apologizing  for 
the  neglect  on  the  ground  that  the  work  was  gratuitous. 
So  it  might  have  been,  but  this  neglect  is  unpardonable 
when  it  is  remembered  that  their  work  was  experimental, 
of  which  they  intended  to,  and  did,  publish  what  results 
they  could. 

It  is  to  be  remarked  that  the  disease  known  in  India  as 
bussunt,  mhata,  or  gotee,  as  described  by  Mr.  Lamb,  bears 
so  close  a  likeness  to  cattle-plague,  that  it  seems  reasonable 

*  Tho  n-r'nei  h&;s  been  informed,  hy  a  native  medical  man  that  many 
of  the  nat'.V'-js  prefer  inoci  fiat1" on  \yith  small-pox  rather  than  vaccination. 


THEORY  AND  PRACTICE  OF  VACCINATION 


to  suppose  that  the  disease  which  Mr.  Furnell  first  witnessed 
was  the  cattle-plague,  and  that  the  see-saw  vaccination 
(so-called)  between  Mr.  Furnell  and  the  native  vaccinators 
became  ultimately  inoculation  of  small-pox. 

It  may  also  be  observed  that  the  experiments  of  Mr. 
Macpherson  were  made  shortly  after  the  publication  of 
Dr.  Baron's  '  Life  of  Jenner,*  who  in  Chapter  V.,  p.  161, 
gives  a  most  interesting  and  learned  disquisition  on  the 
history  of  small-pox,  but  in  which  he  regards  small-pox  and 
cattle-plague  as  identical  diseases. 

Such  are  the  leading  arguments  and  facts  in  favour  of 
vaccinia  being  but  a  modified  form  of  small-pox,  and  if 
true,  then  small-pox  is  the  origin  both  of  cow-pox,  horse- 
pox,  and  camel-pox,  and  Jenner  was  most  probably  correct 
in  his  observations,  but  mistaken  in  their  interpretation. 
*  This  was  published  in  1827. 


Bailliere,  Tindall  and  Ccn,  *20  &  21  ^Kinr,  IVUVan-'  Pinel' Strand,  J.cvdcn. 


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